Dural arteriovenous fistulas with intracranial hemorrhage: diagnostic and therapeutic aspects

Seven patients presented with intracranial hemorrhage due to arteriovenous dural fistula. Six patients showed intracerebral hemorrhage combined with subdural hematoma and intraventricular hemorrhage in one case respectively, and one patient had infratentorial subarachnoid hemorrhage. Location of the fistulae was frontobasal (n=2), tentorium (n=2), transverse sinus (n=2), and superior sagittal sinus (n=1). Angiography revealed reflux into cortical veins in all cases. Therapy was surgery in both cases with fistula of the anterior cranial fossa with good results. An endovascular intraarterial therapy was performed in a case with circumscribed fistula of the superior sagittal sinus, this patient developed a second dural fistula during follow-up. Two patients with tentorial fistulae had primary endovascular treatment complicated by infarction of both thalami in one case and a recurrence of the fistula in the other. In the last case the fistula was closed by surgery. Out of two patients with widespread fistulae of the transverse sinus one made a good clinical recovery and the other remained unchanged. In the first case definite closure of a remnant of the fistula was refused, in the second no further therapy was recommended.     

Multidisciplinary treatment of cavernous sinus dural arteriovenous fistulae with radiosurgery and embolization.

OBJECTIVE: With the advent of interventional neuroradiology and stereotactic radiosurgery, dural arteriovenous fistulae are less often managed with open surgery. We evaluated the outcome of dural arteriovenous fistulae of the cavernous sinus treated with a combination of radiosurgery and embolization. MATERIAL AND METHODS: Twenty dural arteriovenous fistulae located in the cavernous sinus were enrolled in our study. Fifteen patients received X-knife radiosurgery alone and 5 also required embolization, one before radiosurgery and 4 after radiosurgery. The mean volume of the lesions was 2.8 ml (range 0.2-12.6), the corresponding radiation volume was 6.5 ml (range 0.6-24.6), and the conformity index was 2.9 (range 1.8-5.3). The mean peripheral and maximum radiation dose was 17.8 Gy (range 17-20) and 28.3 Gy (range 19-37) Gy, respectively. The clinical and imaging data were analyzed. RESULTS: The mean follow up period was 29 months (23-39). Seventy-five percent (15/20) of patients receiving radiosurgery alone achieved a symptomatic cure and with additional embolization 90% (18/20) were cured. All patients achieved cure on imaging after radiosurgery alone or in combination with embolization. Abnormal imaging findings were observed in two patients after treatment, one had an intracerebral hemorrhage and the other radiation edema, but both were asymptomatic. CONCLUSION: With multidisciplinary treatment with combined radiosurgery and embolization, satisfactory results can be achieved for dural arteriovenous fistulae with a low complication rate. In patients with mild symptoms, radiosurgery is the initial treatment option. Embolization should be performed in patients with severe symptoms or who have failed radiosurgery.     

Dural fistulae of the tentorium cerebelli. Radioanatomical, clinical and therapeutic considerations

Among the 84 intracranial dural fistulae treated in the Neuroradiology department of the University Hospital Centre of Nancy between August 1983 and April 1990, 10 (11.9%) were located on the tentorium cerebelli. The patients were 7 men and 3 women aged from 41 to 61 years at the time of diagnosis. All tentorial dural fistulae showed an exclusively cortical drainage, and only one of them was associated with probable thrombosis of a major sinus. Nine patients presented with at least one episode of neurological deficit (including 2 with progressive ascending myelopathy) associated with a cerebro-meningeal haemorrhage in 6 cases. In all patients the initial treatment was an endovascular one, subsequently reinforced by surgery in 2 patients. In every case the clinical condition was improved or stabilized and no recurrent haemorrhage was observed, but radioanatomical cure was obtained in only 3 patients: 1 treated by the endovascular route and 2 by embolization combined with surgery. The anatomical, physiopathological and clinical aspects of these particular fistulae and the different possible therapeutic approaches are discussed.     

上矢状窦中后部脑膜瘤导致静脉窦闭塞后静脉代偿特点及意义

目的 探讨中、后部矢状窦旁脑膜瘤导致静脉窦闭塞后静脉代偿特点以及全切除肿瘤的手术要点。方法 分析15例中、后部上矢状窦完全闭塞的窦旁脑膜瘤的脑血管造影表现，探讨其静脉回流代偿的形式对手术疗效的影响。结果 静脉回流代偿的形式有三种：(1)皮层浅静脉端-端吻合，主要流向侧裂、Labbe静脉；(2)脑膜静脉流向蝶顶窦、海绵窦；(3)板障静脉流向头皮。本组肿瘤全切除12例，无手术死亡，术后发生三肢瘫1例，双下肢瘫1例，高颅压、失明1例。结论 术前仔细研究血管造影上静脉回流代偿的形式，有助于术中加强对其保护，减少全切除肿瘤手术后的严重并发症的发生。     

球囊辅助栓塞硬脑膜动静脉瘘

目的评估球囊辅助栓塞硬脑膜动静脉瘘的临床效果。方法回顾性分析2010年10月至2012年8月收治的17例硬脑膜动静脉瘘患者的临床资料,其中位于横窦、乙状窦区11例,颈静脉孔区4例,上矢状窦区2例;均行球囊辅助栓塞硬脑膜动静脉瘘;6例经动脉途径栓塞,3例经静脉途径栓塞,8例经动脉及静脉相结合途径栓塞。结果 17例患者中,栓塞后即刻造影复查示,瘘口完全消失11例,部分消失6例。17例病人随访3个月~2年,无加重及复发者;瘘口完全消失13例,部分消失4例。结论球囊辅助栓塞硬脑膜动静脉瘘是一种安全、有效的方法。     

Surgical treatment of high grade dural arteriovenous fistulae

Dural arteriovenous fistulae (dAVF) with direct cortical venous drainage (CVD, Borden Type III) have a high risk of hemorrhage, particularly when symptomatic. Stereotactic radiosurgery is therefore not recommended, and endovascular treatment can be limited by access, incomplete obliteration, and recanalization. Of 70 cerebral dAVF seen at our institution over the past 8 years, 35 were Borden Type III (50%). Twenty-four were treated via microsurgery (69%). Presentation included hemorrhage in nine patients (38%), nonhemorrhagic neurologic deficits in five (21%), asymptomatic in five (21%), headache in three (13%), and seizure in two patients (8%). Only eight of 19 patients with symptomatic dAVF were independent (modified Rankin Scale [mRS] 0–2) preoperatively (42%). The dAVF location was tentorial in six patients (25%), petrosal in six (25%), superior sagittal sinus in four (17%), torcular in two (7%), floor of the anterior fossa in two (7%), and sphenoid ridge, transverse-sigmoid, inferior sagittal sinus and jugular in one patient each (4%). Four patients had failed endovascular therapy (17%). The angiographic obliteration rate was 96%. The combined permanent morbidity and mortality rate was 17%. After a mean follow-up of 2.1 years, 13 patients improved (54%), seven were the same, (29%) and four were worse (17%). Thirteen patients were asymptomatic (mRS 0, 54%), and 18 were independent (mRS 0–2, 75%). Our results reinforce that surgical treatment of dAVF with direct CVD is associated with a high angiographic cure rate with acceptable morbidity and mortality, particularly in light of the lesions’ natural history.     

Endovascular management of carotid cavernous fistulae: observation on angiographic and clinical results

Twenty-five patients with carotid cavernous fistulae (CCFs) were managed at our institute during a five-year period. Transarterial and transvenous treatment of traumatic carotid cavernous fistuale using the detachable balloon technique was performed in 21 patients resulting in angiographic and clinical cure in 20 patients and fatal outcome in one patient following venous rerouting. Surgical ligation of the infraclinoid internal carotid artery was needed in one patient. Preservation of the carotid artery was possible in 16 patients. Four patients with spontaneous CCFs were advised digital compression of carotid arteries resulting in complete closure of the fistula in one and considerable clinical improvement in two patients. One patient required transarterial obliteration of the fistula via the middle meningeal artery by means of a platinum coil and normal butyl cyanoacrylate (NBCA) resulting in total radio anatomical cure.     

“S”形切口+跨窦骨瓣开颅术治疗跨上矢状窦硬膜外血肿的疗效

目的 探讨“S”形切口+跨窦骨瓣开颅术治疗跨上矢状窦硬膜外血肿的疗效。方法 回顾性分析2017年12月至 2019年12月收治的19例跨上矢状窦硬膜外血肿的临床资料。术前行颅脑冠状位、矢状位CT及颅骨三维重建,根据影像学所示行“S”形皮瓣+跨窦骨瓣开颅术。结果 术中见顶骨凹陷性骨折7例,颞顶骨骨折15例,其中骨折线跨上矢状窦12例;上矢状窦出血12例,骨折板障出血3,导静脉及硬膜血管出血4例;术后24~72 h多次复查头部CT,显示硬膜外血肿完全清除,无再出血。出院时按GOS评分评估预后:恢复良好14例,中残3例,重残1例,植物生存1例。术后随访3~24个月无血肿复发。结论 采用“S”形切口+跨窦骨瓣开颅术治疗跨上矢状窦硬膜外血肿,能有效地止血并处理上矢状窦损伤,同时避免上矢状窦受压,术后再出血风险低,并发症少,疗效好。     

经眼上静脉途径栓塞海绵窦区硬脑膜动静脉瘘

目的 探讨经眼上静脉途径栓塞治疗海绵窦区硬脑膜动静脉瘘的临床效果. 方法 对27例海绵窦区硬脑膜动静脉瘘患者行经眼上静脉途径栓塞治疗,通过脑血管造影及临床随访来评价临床疗效. 结果 术后即刻造影示瘘口完全闭塞15例,瘘口处血流速度明显减慢12例.11例患者术后眼球水肿一过性加重.随访3月～4年,临床症状消失17例,症状明显缓解10例. 结论 经眼上静脉途径栓塞治疗海绵窦区硬脑膜动静脉瘘对部分患者是一种有效的治疗方法 .     

脑静脉窦血栓经颅多普勒超声监测的临床意义

目的探讨经颅多普勒超声(TCD)监测上矢状窦血栓患者颅内压(ICP)的可行性,研究TCD动脉、静脉参数及频谱形态与ICP的关系,以指导临床治疗、评价疗效及判定预后。方法选择18例上矢状窦血栓形成住院患者,取入院第1、7及14天为观察点,动态监测患者的ICP、脑灌注压(CPP)、波动指数(PI)、阻力指数(RI)、大脑中动脉(MCA)和大脑中深静脉(dMCV)平均血流速度(Vm)以及TCD频谱形态,并与对照组相比较,同时进行相关性分析。结果上矢状窦血栓患者各观察点参数与对照组相比均有显著性差异(t=6.32,P<0.05),随着ICP的升高,患者的dMCV平均血流速度、PI及RI呈上升趋势,MCA平均血流速度和CPP呈下降趋势,在第7天达到高峰,持续到两周时略有恢复,但仍维持在较高水平。ICP与P1呈明显正相关(P<0.01,r=0.859);ICP与MCA-Vm呈明显负相关(P<0.01.r=-0.638);ICP与dMCV-Vm无相关性(r=0.07,P>0.05)。随着ICP的升高,动脉频谱表现为舒张期和收缩期血流的不同步下降,静脉频谱呈现血流升高的特征,表现为血流量与血管径的同步增加。结论TCD对临床可疑脑静脉窦血栓形成的患者是一种有效的筛选检测手段,TCD动态监测脑静脉窦血栓患者动脉和静脉血流的同步变化可以评估ICP增高的程度和脑部灌注情况,为临床治疗提供科学依据。     

静脉窦区颅骨凹陷性骨折的治疗策略

目的探讨静脉窦区颅骨凹陷性骨折的治疗策略。 方法回顾性分析福建医科大学福总临床医学院（第九〇〇医院）神经外科自2014年10月至2019年10月收治的静脉窦区凹陷性颅骨骨折患者的临床资料，观察保守治疗、骨折区手术及远隔部位手术的临床疗效。 结果研究共纳入35例患者，其中骨折区主要位于上矢状窦前1/3段14例，位于上矢状窦中1/3段9例，位于上矢状窦后1/3段11例，跨左侧横窦1例。保守治疗9例，均治愈出院。行手术治疗26例，其中8例行凹陷性骨折远隔区域硬膜下血肿清除+去骨瓣减压术，18例行骨折片整复及同部位硬膜外血肿清除术。26例手术患者中5例死亡，21例患者临床症状和神经功能均在较短时间内改善。 结论对于静脉窦区凹陷性颅骨骨折患者，应选择谨慎的手术方式及时机，有效控制手术出血，尽可能修补静脉窦壁的破损，并降低后期静脉循环障碍的发生率。     

Diffusion-Weighted Magnetic Resonance Imaging of Spontaneous Venous Infarction and Cortical Hemorrhage Complicating Dural Arteriovenous Fistula

Dural arteriovenous fistula (DAVF) is an abnormal arteriovenous shunt that occurs in the dura matter within or near a dural sinus. The clinical manifestations vary. The authors report herein a rare case of type III DAVF presenting with coexisting intracranial hemorrhage (ICH) and venous infarction evidenced by computed tomography (CT) and diffusion-weighted magnetic resonance imaging. Conventional angiography proved that the right middle meningeal artery and the occipital artery supplied the DAVF, with direct drainage into the cortical veins and superior sagittal sinus.     

家兔上矢状窦中1/3及其回流静脉结扎动物模型的建立

目的 建立一种新的上矢状窦中1／3及其回流静脉结扎的家兔动物模型，为上矢状窦的外科研究提供实验基础。方法 显微镜下暴露兔脑上矢状窦中1/3，用9-0无损伤显微缝合线结扎。同时结扎矢状窦两侧直径〉0．8mm的所有回流静脉。术后观察动物行为及脑组织病理变化，测定脑组织含水量。结果 上矢状窦中1/3及其回流静脉结扎可引起家兔偏瘫、肌张力减低等神经功能障碍，但大多能长期存活。结扎后主要病理改变：神经元变性，神经细胞与胶质细胞水肿。线粒体结构模糊．内质网扩张及窦旁皮质组织水肿；均能逐渐恢复。结论 家兔上矢状窦中1／3及其回流静脉结扎模型操作简单，易控制，稳定，重复性较好，病死率低，是比较理想的研究上矢状窦结扎的实验模型．     

Venous transcranial Doppler in acute dural sinus thrombosis

The value of conventional transcranial Doppler ultrasound in the diagnosis and monitoring of cerebral vein thrombosis is unclear. Previous studies have suggested the usefulness of this method in two cases with superior sagittal sinus thrombosis that showed increased velocities of deep cerebral veins. The purpose of the present study was to evaluate the deep intracranial venous circulation in patients with that pathology. Venous transcranial Doppler ultrasound was performed with a range-gated 2 MHz transducer in 17 healthy volunteers and in six cases of proven acute superior sagittal sinus thrombosis. Peak systolic, end diastolic and mean blood flow velocities were measured in the basal vein of Rosenthal (BVR) and deep middle cerebral vein (DMCV) through a posterior temporal window. In 16 controls and in one patient, the straight sinus was also studied through an occipital approach. Sex distribution and mean age of controls and patients were similar. Mean blood flow velocities in controls were as follows (mean, SD): DMCV, 10.4, 1.4 cm/s; BVR, 11.3, 1.8 cm/s; straight sinus, 29.5, 9.9 cm/s. Three of the patients with superior sagittal sinus thrombosis showed increased velocities either in the DMCV, the BVR or the straight sinus. One patient showed slightly increased velocities in the BVR, and the other two showed normal venous velocity values. This study confirms the usefulness of conventional transcranial Doppler ultrasound in detecting superior sagittal sinus thrombosis. However, a normal examination does not exclude this diagnosis. Received: 7 August 1997 Received in revised form: 9 December 1997 Accepted: 31 December 1997     

矢状窦、镰旁巨大脑膜瘤的显微外科治疗

目的探讨上矢状窭、镰旁巨大脑膜瘤的术前设计及术中处理上吻合静脉、上矢状窦的方法,提高矢状窦、镰旁巨大脑膜瘤的手术疗效。 方法回顾性分析南昌大学第二附属医院神经外科自2001年1月至2010年12月收治的35例矢状窦、镰旁巨大脑膜瘤患者的临床资料,患者均经充分的术前准备并设计较详细的手术方案,行显微手术全切或次全切除术,术中对受累的上吻合静脉、上矢状窦、硬脑膜及颅骨做相应的处理。 结果35例患者中肿瘤切除达到Simpson Ⅰ级21例,SimpsonⅡ级12例,SimpsonⅢ级2例。术后遗留颅骨缺损5例;单侧肢体瘫痪（肌力Ⅰ～Ⅳ级）5例,双下肢瘫痪（肌力Ⅰ～Ⅱ级）1例,经高压氧、针灸理疗等综合治疗1～6个月后均恢复正常。随访6～24个月,SimpsonⅢ级切除者2例复发。 结论通过术前充分的MRI、MRA、DSA、CTA等影像学评估及设计较详细的手术方案,术中采用显微外科技术、有效地控制出血、妥善处理好上矢状窦及受累的上吻合静脉、避免正常脑组织医源性损伤、尽可能全切或次全切除肿瘤,是提高矢状窦、镰旁巨大脑膜瘤手术疗效的重要因素。     

Evolution of angiographic signs of venous hypertension and clinical signs of intracranial hypertension in intracranial dural arteriovenous fistulas]

Dural arteriovenous fistulas (dAVFs) can cause cerebral venous hypertension (VHT). The most common mechanism is due to the fact that some dAVFs can drain retrogradelly in cortical (better defined as leptomeningeal) veins (directly or after drainage in a dural sinus) causing venous engorgement and consequently an impairment of the cerebral venous drainage. However, more rarely, dAVFs without a cortical venous drainage can also be responsible for VHT probably due to dAVF shunts causing insufficient antegrade cerebral venous drainage. In addition, dAVFs are often associated with stenosis and/or thrombosis of dural sinus(es) which can worsen the VHT. Raised pressure within the superior sagittal sinus causes impeded cerebrospinal reabsorption in the arachnoid villi allowing increased intracranial pressure. The venous engorgement in the cortical veins can cause a venous congestive encephalopathy analogous to the venous congestive myelopathy of the spinal dural AVFs. Clinically VHT can cause not only symptoms related to increased intracranial pressure but also seizures, neurological deficits, impairment of the cognitive functions and dementia. An important aspect is the risk of hemorrhage in dAVFs with a leptomeningeal venous drainage leading to VHT. Although the term VHT sensu strictu should be used if venous pressure measurements are performed, angiographic criteria for VHT such as delayed circulation time, venous engorgement and abnormal visualization of the cerebral veins are well established. The purpose of our study was to evaluate the angiographic signs of VHT in patients with dAVF and to study the course of the VHT and of the clinical signs of increased intracranial pressure before and after dAVF endovascular treatment. A retrospective chart analysis of 22 patients (13 males, 9 females) ranging in age from 20 to 87 years (mean: 53 ys.) with a dAVF associated with angiographic signs of VHT was performed. Ten dAVFs were located on the transverse/sigmoid sinus(es), 6 on the superior sagittal sinus, 3 on the petro-tentorial incisura, 1 on the inferior petrosal sinus, 1 on the anterior ethmoidal region and 1 on the Galen vein region. All dAVFs had a retrograde leptomeningeal venous drainage. Stenosis or thrombosis of the dural AVF sinus was observed in 17 cases and stenosis or thrombosis of another sinus(es) and/or of the jugular vein in 8 cases. In 11 patients, the angiographic signs of VHT were global affecting the entire cerebral venous drainage and, in the other 11 patients, the VHT was focal. The VHT caused clinical symptoms of increased intracranial pressure in 18 patients. Other clinical findings included: bruit (11 cases), seizures (3 cases), vertigo (3 cases), visual deficits (2 cases) and impairment of cognitive functions (4 cases). Three patients presented hemorrhage (one parenchymal hematoma, one hemorrhagic infarction and one subarachnoid hemorrhage). The 4 patients without clinical symptoms of increased intracranial pressure presented only bruit in 2 cases, bruit and vertigo in 1 case, bruit and hemorrhagic infarction in another one. The dAVFs were treated by endovascular therapy (arterial approach: 3 cases, venous approach: 6 cases and both arterial and venous approach: 13 cases). Endovascular sessions ranged from 1 to 7 (mean: 2.8) for each patient. After the endovascular treatment, in 12 patients with complete occlusion of the dAVF, the disappearance of angiographic signs of VHT and clinical cure were observed. In 8 patients with partial occlusion of the dAVF, the disappearance of angiographic signs of VHT and clinical cure were observed in 4 cases (almost complete dAVF occlusion in 2 cases); in the other 4 cases, only reduction the angiographic signs of VHT and clinical improvement were obtained. In all 16 patients who were clinically cured angiographic signs of VHT disappeared despite the persistence of dAVF shunts as observed in 4 cases. (ABSTRACT TRUNCATED)     

上矢状窦旁中后1/3脑膜瘤术中回流静脉的保护

目的探讨上矢状窦旁中后1/3脑膜瘤术中如何保护回流静脉,以提高手术治疗效果。方法回顾性分析2002年11月至2010年12月应用回流静脉保护技术治疗上矢状窦旁中后1/3脑膜瘤42例,术前均行MRV检查,术中采取跨中线骨瓣,绕行剪开硬膜,妥善处理肿瘤与中央沟静脉粘连和受累的矢状窦。采取传统手术20例。结果采取回流静脉保护组回流静脉均保护完整,无神经功能障碍加重。传统手术组4例因术中回流静脉损伤而出现偏瘫、颅高压症状,1例行去骨瓣减压术,2例上肢遗留偏瘫。结论应用术前MRV检查和术中注意回流静脉的保护等显微技术切除上矢状窦旁中后1/3脑膜瘤可减少脑重要功能区的损伤,提高术后患者生存质量。     

大型矢状窦旁脑膜瘤显微外科治疗

目的探讨显微外科技术在大型矢状窦旁脑膜瘤手术中的应用。方法肿瘤位于矢状窦前1/3有6例,中1/3有13例,后1/3有8例;其中跨上矢状窦两侧的有2例,颅骨侵犯的2例,软组织侵犯的1例合并有肿瘤卒中。采用跨中线骨瓣,显微手术技术切除27例上矢状窦旁大型脑膜瘤。结果肿瘤SimpsonⅠ级16例,SimpsonⅡ级8例,SimpsonⅢ级3例;术后回访3~36个月,1例术后二个月复发。结论采用显微外科技术,暴露上矢状窦,充分显露肿瘤,有效控制出血,保护回流静脉,可减少并发症。     

兔上矢状窦中1/3及其回流静脉结扎后颅内压变化

目的探讨兔上矢状窦中1/3结扎与上矢状窦中1/3及其回流静脉结扎后颅内压的变化,为矢状窦旁中1/3脑膜瘤、矢状窦中1/3损伤的治疗提供新思路和实验依据。方法 30只健康家兔,随机分为3组,假手术对照(SO)组10只、上矢状窦中1/3结扎(SSS)组10只、上矢状窦中1/3及其回流静脉结扎(SSS+RV)组10只。建立兔上矢状窦中1/3结扎与上矢状窦中1/3及其回流静脉结扎的动物模型,用光导纤维颅内压监护仪监测结扎后4 h内颅内压的变化。结果家兔上矢状窦中1/3结扎后颅内压逐渐上升,3 h又下降,并维持此水平至4 h,与SO组比较无显著性差异(P>0.05);上矢状窦中1/3及其回流静脉结扎30 min后颅内压开始逐渐上升,约2.5 h后上升明显(P<0.05),与SO组和SSS组相应时间点相比均有显著性差异(P<0.05)。结论单纯上矢状窦中1/3结扎后颅内压变化不大。上矢状窦中1/3及其回流静脉结扎后4 h内颅内压逐渐升高。     

Clinical characteristics of dural arteriovenous fistula.

Intracranial dural arteriovenous fistula (DAVF) is an uncommon neurosurgical condition; in particular, it has been infrequently reported in Korea. To understand the general clinical characteristics of DAVFs, the authors reviewed 53 cases and analyzed factors affecting DAVF hemorrhage of and treatment outcome. Since 1980 we have encountered 480 pial and 53 DAVFs, a ratio of 9.1 to 1. The age of these patients ranged from 1 month to 71 years, the most common being in the 6th decade, and females exceeded males by 1.65 to 1. All lesions except three were single, and symptoms were related to location and the venous drainage pattern. The most common location was the cavernous sinus, accounting for about 64% of cases, with the result that the most common clinical symptoms of DAVFs were ocular, namely proptosis and chemosis. The next was tinnitus also found in transverse-sigmoid sinus DAVFs. Intracranial hemorrhage was seen in eight cases,(15%) the primary cause of hemorrhage was retrograde intracranial venous drainage (P=0.017), and one hemorrhage was observed in cases with no intracranial venous drainage. Intracranial hemorrhage was more frequently in transverse-sigmoid than cavernous sinus DAVFs (P=0.049), and this proved to be so even where there was intracranial venous drainage. However, two of 34 patients with cavernous DAVFs became blind in one eye, demonstrating that in such patients, the clinical course could be aggressive. Thirteen patients were treated conservatively. The conservative treatment group was comprised of 13 patients, two of three patients with transverse-sigmoid sinus DAVF expired, and 7 of 10 with cavernous sinus DAVF experienced a clinical improvement or cure. Surgical excision was performed in only two patients. A total of 39 patients underwent embolization; clinical cure was achieved in 13, improvement of symptoms in 12, an unchanged or aggravated result occurred in 9, one died, and four were lost to follow up. During intervention, there was one hemorrhagic complication, owing to obstruction of the venous outflow with embolic materials.In this study, the most common location of DAVFs was the cavernous sinus. The cortical venous drainage remains the primary determinant of intracranial hemorrhage. Common indications for treatment include hemorrhage and neurological deficit. Endovascular treatment is preferred in the majority of cases except tentorial DAVF. The goal of embolization in cavernous DAVF is the alleviation of symptoms, not angiographic cure. But transverse-sigmoid sinus DAVF with venous restriction and leptomeningeal drainage should be treated aggressively.