Dural arteriovenous fistula: Diagnosis, treatment, and outcomes

Renal Arteriovenous (AV) Fistula after High-Grade Blunt Renal Trauma Caused by Traffic Accidents

PURPOSE

To report a series of three patients with traumatic renal AV fistulas after blunt renal laceration.

METHODS

We retrospectively analyzed the renal trauma cases treated in the Department of Urology of Salzburg University Clinic during a time period of 10 years concerning traumatic AV fistula formation and other clinical parameters.

RESULTS

In total, 3 cases of traumatic AV fistula formation were identified in 106 blunt renal trauma patients (2.8%), with a mean age of 39 (17-56) years. All renal traumas were classified as American Association for the Surgery of Trauma (AAST) grade IV. Two patients were primarily treated with ureteral stent; one was managed conservatively. All AV fistulas were diagnosed after a mean time of 7 (1-13) days. Two patients were symptomatic with gross hematuria, and the mean time between trauma and onset of symptoms was 11 (9-13) days. All cases were managed via coil embolization after a mean of 10 (8-13) days. Two patients received a second intervention after a mean of 18 (11-25) days. The mean AV fistula size was 18.7 (12-24) mm. Mean hemoglobin loss was 3.6 g/dL. One patient received one erythrocyte concentrate. Discharge was after a mean time of 13.3 (7-12) days, with the mean time of intensive care treatment being 2.3 (1-3) days.

CONCLUSIONS

Traumatic renal AV fistula is a rare but severe complication associated with higher-grade renal trauma. It can become evident through hematuria or blood loss several days after the initial trauma. The availability of coil embolization in a trauma center can help kidney preservation management.

Intracranial Dural Arteriovenous Fistulas

Dural arteriovenous fistulas (DAVFs) are abnormal communications between meningeal arteries and dural venous sinuses and/or cortical veins. Although many fistulas are benign and do not require treatment, some may carry a significant risk of bleeding or cause symptoms and warrant treatment. This review provides a review of various aspects of intracranial DAVFs including epidemiology, pathophysiology, clinical presentation, imaging characteristics, classification, natural history, and management options. By exploring these topics, we aim to enhance understanding of this condition and facilitate patient care.

Bold-S Signs on Computed Tomography Angiography Are Sensitive Markers for Diagnosing Subcortical Hemorrhage Due to Dural Arteriovenous Fistulae on Emergent Admission

An optimal treatment strategy for subcortical hematomas caused by dural arteriovenous fistulae (dAVF) is important because of the high rebleeding rate. However, it is very difficult to diagnose that on admission. Therefore, an early sensitive predictive marker for subcortical hemorrhage caused by dAVF is necessary, especially during the first contact on admission. S-shaped dilated vessels around the hematoma (bold-S sign) on computed tomography angiography (CTA) performed during admission could be one such marker. Herein, we evaluated the characteristics of these vessels. Among 273 patients with intracerebral hemorrhage between April 2012 and March 2020, 67 patients with subcortical hematomas who underwent CTA on admission without arteriovenous malformations were included. The patients in the dAVF group (n = 7) showed fewer disturbances in consciousness, milder neurological deficits, and more frequent seizures than patients without dAVF (without dAVF group, n = 60). All patients in the dAVF group had dilated S-shaped vessels (2.59 ± 0.27 mm) around the hematomas, and only 20% of the patients in the without dAVF group had these vessels (1.69 ± 0.22 mm). The ratio of the ipsilateral S-shaped/contralateral largest vessels was 1.80 ± 0.29 in the dAVF group and 1.07 ± 0.16 in the group without dAVF. We called the dilated S-shaped vessels the "bold-S sign," with a cutoff ratio of 1.5. Bold-S sign findings are novel and help in diagnosing subcortical hematomas caused by dAVF on admission.

Incidental vascular findings on brain magnetic resonance angiography

Given the ever-increasing utilization of magnetic resonance angiography, incidental vascular findings are increasingly discovered on exams performed for unconnected indications. Some incidental lesions represent pathology and require further intervention and surveillance, such as aneurysm, certain vascular malformations, and arterial stenoses or occlusions. Others are benign or represent normal anatomic variation, and may warrant description, but not further work-up. This review describes the most commonly encountered incidental findings on magnetic resonance angiography, their prevalence, clinical implications, and any available management recommendations.

Petrous apex's dural arteriovenous fistula (DAVF) mimicking a pineal region tumour: a rare cause of Hakim triad

A dural arteriovenous fistula (DAVF) is a dural-based shunt between meningeal arteries and meningeal veins, sinuses and/or cortical veins; they have been classified and named according to the location and the flow pattern. Petrous apex DAVFs are located where the petrosal vein penetrates the dura mater into the superior petrosal sinus; there are only few cases reported in the literature, they can show an aggressive behaviour (subarachnoid haemorrhage, severe brainstem oedema) with a high mortality rate. The described case is, to the best of our knowledge, the first case of a DAVF presenting with symptoms mimicking idiopathic normal pressure hydrocephalus. After worsening of gait impairment, memory loss and urinary incontinence an urgent CT of the brain showed hydrocephalus and a hyperdense mass in the pineal region mimicking a pineal tumour; an emergent digital subtraction angiogram showed a left petrous apex Borden type III DAVF. A transvenous embolisation was performed obtaining a complete obliteration.

Differential subsampling with cartesian ordering: A high spatial-temporal resolution dixon imaging sequence for assessment of dural arteriovenous fistula

Objective

To evaluate the accuracy of differential subsampling with cartesian ordering (DISCO) in comparison to time of flight (TOF) in detecting dural arteriovenous fistulas (DAVF), cerebral venous thrombosis (CVT) and hemodynamics.

Methods

Sixty-two cases (24 female; aged 14–75; mean age, 51.3 years) were included in our study, with 42 positive and 20 negative cases via Digital Subtraction Angiography (DSA). Two neuroradiologists independently evaluated the DISCO and TOF. The sensitivity, specificity, and accuracy of the DISCO and TOF-MRA were individually calculated using DSA as the gold standard. Inter-observer reliability was assessed by using a weighted Cohen's kappa (κ) test; P < 0.05 was set as the threshold for statistical significance.

Results

Diagnostic sensitivities of DISCO and TOF for DAVF were 92.86 and 64.29%; specificities were 95.0% and 95.0%; while accuracies were 93.55 and 74.19% respectively. For detected CVT, sensitivities of DISCO and TOF were 100 and 92.31%; specificities were 96.55 and 93.10%; with accuracies 97.62 and 92.86% respectively. In hemodynamic analysis, sensitivity of DISCO for reflux was 95.45%; with a specificity of 95.0%; and accuracy 95.24%. The inter-observer kappa values were 0.857 for DISCO (P < 0.001).

Conclusion

DISCO showed a high degree of sensitivity and specificity, suggesting its effectiveness in detecting DAVF with or without CVT. Intracranial hemodynamics can be identified using DISCO in DAVF patients, providing accurate evaluation of cerebral blood flow dynamics during the pre-treatment phase.

Dual-phase contrast-enhanced CT evaluation of dural arteriovenous fistula in patients with pulsatile tinnitus as an initial symptom

PURPOSE

Intracranial dural arteriovenous fistula (DAVF) can cause pulsatile tinnitus (PT). The purpose of this study was to investigate the diagnostic performance of dual-phase contrast-enhanced CT (DP-CECT) for DAVF in PT patients compared with digital subtraction angiography (DSA).

METHOD

From February 2015 to April 2021, PT patients undergoing routine DSA examination were prospectively analyzed. Patients with and without DAVF diagnosed by DSA were included. In DP-CECT, the radiological signs related to DAVF were assessed as follows: asymmetric external carotid artery (ECA) branches, asymmetric enhancement of intracranial or extracranial veins, asymmetric venous collaterals in extracranial space, and shaggy tentorium or venous sinus on CTA; asymmetric enhancement of intracranial or extracranial veins on CTV; numerous transcalvarial channels and asymmetric size of foramen spinosum on high-resolution CT (HRCT).

RESULTS

253 PT patients receiving DSA were enrolled, and these patients had previously been screened by DP-CECT. Forty-six patients were diagnosed as DAVF by DSA. Therefore, the prevalence of DAVF was 18% (46/253) in patients with PT as the initial symptom. The sensitivity and specificity of DP-CECT for diagnosis of DAVF were 96% and 100%. The sensitivity of individual CTA signs ranged from 65% to 93%, and specificities ranged from 83% to 100%. The sensitivity of CTV sign was 80%, and specificity was 100%. The sensitivity of individual HRCT signs ranged from 48 to 52% and specificities from 61 to 100%.

CONCLUSIONS

DAVF is not rare in patients with PT as the initial symptom. DP-CECT can be used for screening DAVF in patients with PT.

Traumatic carotid-cavernous fistula with perimedullary venous drainage and delayed myelopathy: A case report

Traumatic carotid-cavernous fistula (TCCF) with perimedullary venous drainage and delayed myelopathy is a relatively rare clinical lesion. Endovascular embolization using embolic agents is the preferred treatment for patients with a poor collateral circulation. The present study describes the case of a 45-year-old male with TCCF, who presented with progressive cervical myelopathy for 1 month. A previous history of the patient included an anterior skull base fracture induced by a traffic accident 2 years prior. Cervical spinal magnetic resonance imaging (MRI) revealed dilated perimedullary veins and cervical spinal cord edema. Cerebral digital subtraction angiography revealed a direct CCF with perimedullary venous drainage. The patient received endovascular treatment with coils and an Onyx liquid embolic system to occlude the fistula, and his symptoms were relieved when he was discharged 3 weeks later. The patient then felt normal and a cervical spinal MRI revealed the disappearance of the perimedullary veins dilation and spinal cord edema at the 6-month follow-up. To the best of our knowledge, only three cases of CCFs with perimedullary venous drainage presenting with myelopathy have been previously reported. The present study also discussed the possible pathological mechanisms for this rare presentation. Moreover, it is suggested that the possibility of CCFs as a cause of cervical myelopathy needs to be taken into consideration.

Incidentally discovered dural arteriovenous fistula during middle meningeal artery embolization for the treatment of chronic subdural hematoma

Background:

The incidence of chronic subdural hematoma (CSDH) is increasing with population age and anticoagulant use. Embolization of the middle meningeal artery (MMA) is an emerging, less invasive alternative to open surgery in treating this condition. Dural arteriovenous fistula (DAVF) is a rare condition whose association with CSDH is not well understood. We present three cases with incidentally discovered DAVFs during MMA embolization for the treatment of CSDH that necessitated adjustments to initial treatment strategy.

Case Descriptions:

We retrospectively reviewed all MMA embolizations performed for the treatment of CSDH beginning in 9/2019 to 11/2020. Imaging and hospital course of three cases of incidentally discovered DAVF, including patient demographics, clinical presentation, methods of treatment, imaging and outcome were assessed. Thirty MMA embolizations were performed as primary or adjunct treatment of CSDH. DAVF was discovered angiographically in 3 (10%) cases. All patients reported a history of prior closed head injury, although the timing of injury and subdural blood product age did not correlate in 2 of the 3 cases. All subjects experienced complete symptomatic and radiographic resolution of the subdural hematoma and DAVF following intervention.

Conclusion:

As MMA embolization for CSDH becomes more frequent, so may the incidental diagnosis of DAVF. Awareness of this potential association is critical to diagnosing DAVF with angiography and altering treatment strategies as needed.

[A dural arteriovenous fistula detected during the chronic phase of cerebral venous sinus thrombosis]

A 47-year-old woman developed a headache and tinnitus in her right ear followed by sudden-onset left hemiparesis. She had no history of trauma or thrombophilia. Arteriography showed an occlusion of the superior sagittal sinus, and a stenosis of the right transverse sinus. She was treated with anticoagulants; thereafter her deficits and sinus thrombosis immediately improved. However, 7 months after the onset, she noticed tinnitus in her left ear. Arteriography showed a dural arteriovenous fistula extending from the left occipital artery to the left transverse and sigmoid sinus, but no recurrence of the cerebral venous sinus thrombosis. After manual compression of the left occipital artery was initiated, the tinnitus and dural arteriovenous fistula did not worsen. A dural arteriovenous fistula may be detected in patients with cerebral venous sinus thrombosis during the chronic phase.

Inner Ear Conductive Hearing Loss and Unilateral Pulsatile Tinnitus Associated with a Dural Arteriovenous Fistula: Case Based Review and Analysis of Relationship between Intracranial Vascular Abnormalities and Inner Ear Fluids

While pulsatile tinnitus (PT) and dural arteriovenous fistula (DAVF) are not rarely associated, the finding of a conductive hearing loss (CHL) in this clinical picture is unusual. Starting from a case of CHL and PT, diagnosed to be due to a DAVF, we analyzed relationship between intracranial vascular abnormalities and inner ear fluids. DAVF was treated with endovascular embolization. Following this, there was a dramatic recovery of PT and of CHL, confirming their cause-effect link with DAVF. We critically evaluated the papers reporting this association. This is the first case of CHL associated with PT and DAVF. We describe the most significant experiences and theories reported in literature, with a personal analysis about the possible relationship between vascular intracranial system and labyrinthine fluids. In conclusion, we believe that this association may be a challenge for otolaryngologists. So we suggest to consider the possibility of a DAVF or other AVMs when PT is associated with CHL, without alterations of tympanic membrane and middle ear tests.

Risk factors for dural arteriovenous fistula intracranial hemorrhage

To our knowledge, the risk factors for intracranial hemorrhage from dural arteriovenous fistula (DAVF) have not been systematically described, due to the complexity of their anatomy and low incidence. We performed this retrospective study to investigate the DAVF factors predicting intracranial hemorrhage. A 10year database of 144 consecutive patients with DAVF was reviewed. Data collected and analyzed were demographics, morphologic features of DAVF, sex, age, fistula flow rate, arterial supply, lesion location, and venous drainage pattern. Linear univariate and multivariate logistic regression analyses were used to evaluate the association between influencing factors and hemorrhage. A first linear univariate analysis was performed for all influencing factors, and showed that sex, lesion location, and venous drainage pattern were statistically significant in predicting intracranial hemorrhage (p<0.05). Secondary multivariate logistic regression analysis with sex, lesion location, and venous drainage pattern showed that only venous drainage pattern was statistically significant in predicting intracranial hemorrhage (p<0.05). Therefore, venous drainage pattern, particularly the cortical venous drainage, significantly predicts intracranial hemorrhage from DAVF. Both sex and lesion location may be confounding factors in predicting intracranial hemorrhage from DAVF, while the other factors may not be associated with hemorrhage.

Intra-arterial intraoperative computed tomography angiography guided navigation: a new technique for localization of vascular pathology

BACKGROUND

Precise intraoperative surgical localization of small distal aneurysms, arteriovenous malformations (AVMs), and cranial base dural arteriovenous fistulae may be challenging. Current neuronavigational techniques are based on imaging techniques with limited sensitivity to detect vascular lesions that are small. We introduce the technique of intraoperative computed tomography angiography (iCTA) with an intra-arterial injection for surgical navigation.

OBJECTIVE

To determine whether iCTA integrated with a navigation platform is accurate and useful for precise localization of small vascular lesions that are challenging to treat.

METHODS

This study included 8 patients: 2 with aneurysms, 3 with small cortical AVMs, and 3 with cranial base dural arteriovenous fistulae. iCTA with intra-arterial contrast injection was performed in all patients for precise localization of the small vascular lesion to facilitate craniotomy planning and microsurgical approach. All operative reports, inpatient and outpatient records, and radiographic studies available were reviewed retrospectively.

RESULTS

: The iCTA was used to target 2 aneurysms, 3 small subcortical AVMs, and 3 dural arteriovenous fistulae. This technique was most helpful to localize the 3 AVMs and the distal M4 aneurysm precisely. Craniotomy planning was accurate in all instances; no complications related to the technique were noted, and all patients had uneventful postoperative recoveries.

CONCLUSION

iCTA is an effective and accurate novel technique that can enhance the safety of surgical treatment for small intra-axial vascular pathology.

ABBREVIATIONS

AVM, arteriovenous malformationCTA, computed tomography angiographyDAVF, dural arteriovenous fistulaDSA, digital subtraction angiographyiCTA, intraoperative computed tomography angiographyMCA, middle cerebral arteryMSCT, multislice computed tomographyMRA, magnetic resonance angiography.

Surgical management of dural arteriovenous fistulas of the transverse-sigmoid sinus in 42 patients

A retrospective study was performed to analyse a prospectively collected database from a single surgeon (M.K.M.) of transverse-sigmoid sinus dural arteriovenous fistulas (DAVF) between 1991 and August 2011. During the study period, 144 patients with 160 DAVF were managed. Sixty-five of the DAVF were located in the transverse-sigmoid sinus and 42 were treated with surgery, or embolisation and surgery. All patients who underwent surgery were symptomatic with retrograde cortical venous drainage. The average follow-up period was 18months (range, 2-82months). Total elimination of the DAVF was achieved in all instances, including two patients (5%) who required further surgery after postoperative cerebral angiography showed that some venous drainage had persisted after the first operation. There was no new permanent neurological deficit or mortality attributable to surgery. Our institutional experience shows that in selected patients with transverse-sigmoid sinus DAVF, the involved sinus can be surgically resected with a high success rate and it is as safe as many alternative options. We suggest that this definitive treatment option should be offered to patients, and the outcome should be compared to other treatment modalities.

Imaging of cerebral arteriovenous malformations and dural arteriovenous fistulas

Imaging plays a major role in the identification, grading, and treatment of cerebral arteriovenous malformations and cerebral dural arteriovenous fistulas. Digital subtraction angiography is the gold standard in the diagnosis and characterization of these vascular malformations, but advances in both magnetic resonance imaging and computed tomography, including advanced imaging techniques, have provided new tools for further characterizing these lesions as well as the surrounding brain structures that may be affected. This article discusses the role of conventional as well as advanced imaging modalities that are providing novel ways to characterize these vascular malformations.

Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment

Intracranial DAVFs are pathologic dural-based shunts and account for 10%-15% of all intracranial arteriovenous malformations. These malformations derive their arterial supply primarily from meningeal vessels, and the venous drainage is either via dural venous sinuses or through the cortical veins. DAVFs have a reported association with dural sinus thrombosis, venous hypertension, previous craniotomy, and trauma, though many lesions are idiopathic. The diagnosis is dependent on a high level of clinical suspicion and high-resolution imaging. Cross-sectional imaging techniques by using CT and MR imaging aid in the diagnosis, but conventional angiography remains the most accurate method for complete characterization and classification of DAVFs. The pattern of venous drainage observed on dynamic vascular imaging determines the type of DAVF and correlates with the severity of symptoms and the risk of hemorrhage.

State of the art in managing nontraumatic intracerebral hemorrhage

Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.

Dural arteriovenous fistula following translabyrinthine resection of cerebellopontine angle tumors: report of two cases

We describe two cases of dural arteriovenous fistula (DAVF) developing in a delayed fashion after translabyrinthine resection of cerebellopontine angle tumors. Two patients in an academic tertiary referral center, a 46-year-old woman and a 67-year-old man, underwent translabyrinthine resection of a 2-cm left vestibular schwannoma and a 4-cm left petrous meningioma, respectively. Both patients subsequently developed DAVF, and in each case the diagnosis was delayed despite serial imaging follow-up. In one patient, cerebrospinal fluid diversion before DAVF was identified as the cause of her intracranial hypertension; the other patient was essentially asymptomatic but with a high risk of hemorrhage due to progression of cortical venous drainage. Endovascular treatment was effective but required multiple sessions due to residual or recurrent fistulas. Dural arteriovenous fistula is a rare complication of translabyrinthine skull base surgery. Diagnosis requires a high index of clinical suspicion and an understanding of subtle imaging findings that may be present on follow-up studies performed for tumor surveillance. Failure to recognize this complication may lead to misguided interventions for treatment of hydrocephalus and other complications, as well as ongoing risks related to venous hypertension and intracranial hemorrhage. As this condition is generally curable with neurointerventional and/or surgical methods, timely diagnosis and treatment are essential.

CT angiography as a screening tool for dural arteriovenous fistula in patients with pulsatile tinnitus: feasibility and test characteristics

BACKGROUND AND PURPOSE

The diagnosis of intracranial DAVF with noninvasive cross-sectional imaging such as CTA is challenging. We sought to determine the sensitivity and specificity of CTA compared with cerebral angiography for DAVF in patients presenting with PT.

MATERIALS AND METHODS

Following approval of the institutional review board, we reviewed all patients who underwent CTA for PT from 2004 to 2009 and collected clinical and imaging data. Seven patients with PT and proved DAVF and 7 age- and sex-matched control patients with PT but no DAVF composed the study group. CTA images were blindly interpreted by 2 experienced neuroradiologists for the presence of 5 variables: asymmetric arterial feeding vessels, "shaggy" appearance of a dural venous sinus, transcalvarial venous channels, asymmetric venous collaterals, and abnormal size and number of cortical veins. Asymmetric attenuation of jugular veins was additionally assessed.

RESULTS

The presence of arterial feeders showed good test characteristics for screening, with a sensitivity of 86% (95% CI, 42-99) and a specificity of 100% (95% CI, 52-100). A shaggy sinus or tentorium was highly specific: sensitivity of 42% (95% CI, 11-79) and specificity of 100% (95% CI, 56-100). The presence of transcalvarial venous channels demonstrated a poor sensitivity of 29% (95% CI, 5-70) but a high specificity 86% (95% CI, 42-99). CT attenuation of the jugular veins showed statistically significant asymmetry in the DAVF group versus the control group (P < .05).

CONCLUSIONS

CTA can be used to screen for DAVF in patients with PT. The presence of asymmetrically visible and enlarged arterial feeding vessels has a high sensitivity and specificity for the diagnosis of DAVF.

The utility of angiographic CT in the diagnosis and treatment of neurovascular pathologies in the vicinity of cranial base

This study aims to explore the utility of angiographic computed tomography (CT) in the diagnosis and treatment of neurovascular pathologies in the vicinity of cranial base. Two cases of cranial base dural arteriovenous fistula, one internal carotid pseudoaneurysm and one PICA aneurysm were demonstrated utilizing the angiographic CT for obtaining significant image details on the relative location of the diseases against the neighboring bony structure. An angiography suite outfitted with conventional DSA and rotational volume cone-beam was used, angiographic CT images being concomitantly produced together with the routine angiographic modalities. By virtue of the angiographic CT images integrating the selective angiography and reconstructed cranial base tomography, we succeeded in getting significant information on the relative location of various vascular diseases to the skull base, greatly facilitating the diagnosis and treatment procedures.

Intracranial dural arteriovenous fistulas: diagnosis and evaluation with 64-detector row CT angiography

PURPOSE

To analyze the diagnostic effectiveness and application of computed tomographic (CT) angiography by using a new algorithm (hybrid CT angiography) in dural arteriovenous fistulas (AVFs).

MATERIALS AND METHODS

Institutional review board approval was obtained for retrospectively postprocessing the raw data from CT angiography by using hybrid CT, which is a mixture of a bone subtraction and masking method for bone removal. The study included 22 patients with 24 dural AVFs and 14 control subjects. The grades in patients with dural AVF determined with hybrid CT angiography and digital subtraction angiography (DSA) were compared, and hybrid CT angiography was applied as a tool for planning endovascular treatment. The adjusted Wald method was used to estimate confidence intervals (CIs), and the Cohen kappa statistic was used to assess interobserver agreement.

RESULTS

Hybrid CT angiography in the 24 dural AVFs revealed asymmetric sinus enhancement in 22 lesions (92%), engorged arteries in 19 (79%), transosseous enhanced vessels in 19 (79%), engorged extracranial veins in 13 (54%), engorged cortical veins in seven (29%), and sinus thrombosis in four (17%). In all 24 lesions, at least two of six imaging signs for diagnosis of dural AVFs were present. The kappa test analysis revealed a high level of interobserver agreement (kappa, 0.56-1.00) in reading the diagnostic imaging signs. The observed agreement between DSA and readers was 100% in the cavernous sinus region and in hypoglossal and clival lesions and 78%-89% in the transverse sigmoid sinus. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 0.93 (95% CI: 0.85, 0.97), 0.98 (95% CI: 0.93, 1.00), 0.97 (95% CI: 0.90, 0.99), and 0.95 (95% CI: 0.90, 0.98), respectively.

CONCLUSION

Hybrid CT angiography is a promising tool for the diagnosis of dural AVF. It can provide key information necessary for treatment planning.

Neuroendovascular management of dural arteriovenous malformations

Dural arteriovenous fistulas are characterized by abnormal arteriovenous shunting localized to the pachymeninges. Fistulae venous drainage is essential to their classification, symptomatology, and treatment. Endovascular therapy is rapidly progressing to an adjunct or even alternative treatment to microsurgical resection. Several techniques, such as transarterial or transvenous embolization with metallic coils, NBCA, or Onyx, have been used successfully in several studies. The long-term clinical and radiographic outcomes of endovascular therapy for the treatment of dural arteriovenous fistulas are satisfactory, and future studies are underway for the refinement of these techniques.