From the Guidelines
Endovascular treatment is the preferred initial approach for ethmoidal dural arteriovenous fistulas due to its effectiveness and lower risk of complications compared to surgery. This is supported by the American Heart Association's scientific statement on indications for intracranial endovascular neurointerventional procedures, which highlights the potential for curative endovascular treatment of dural arteriovenous fistulas with contemporary transvenous or transarterial embolization techniques 1. The benefits of endovascular treatment include:
- Minimally invasive nature
- High success rates
- Lower morbidity
- Shorter hospital stays
- Avoidance of risks associated with open surgery near critical neurovascular structures
Key considerations in the decision between endovascular and surgical approaches include:
- Location of the fistula
- Feeding vessels
- Venous drainage pattern
- Patient's overall clinical condition A multidisciplinary team approach involving interventional neuroradiologists and neurosurgeons is crucial for optimal treatment planning and outcomes, as it allows for individualized decision-making based on the specific characteristics of the fistula and the patient's needs 1.
From the Research
Treatment Options for Ethmoidal Dural Arteriovenous Fistula
The treatment of ethmoidal dural arteriovenous fistula (DAVF) can be approached through either surgery or endovascular methods. The choice between these two options depends on various factors, including the patient's condition, the anatomy of the fistula, and the expertise available.
Surgical Treatment
- Surgical management of ethmoidal DAVFs has been shown to be highly effective in obliterating the fistula and achieving good clinical outcomes 2, 3.
- A low bifrontal surgical approach can be used to expose, coagulate, and divide the fistulous site, with no associated risk to vision 2.
- Surgical disconnection remains the gold standard in the treatment of ethmoidal DAVFs, with a success rate of 100% in some series 3.
Endovascular Treatment
- Endovascular treatment of ethmoidal DAVFs has become technically feasible, but its relative risks and benefits have not always justified its use 2.
- Embolization with casting of the draining vein can be successful in selected cases, but it is rarely effective in curing the fistula and does not eliminate the need for surgery 3.
- Transvenous endovascular approaches can be useful in treating ethmoidal DAVFs, but access and tortuosity of structures proximal to the fistula point must be thoroughly assessed 4.
- Endovascular therapy can be effective and safe in selected patients, but surgical ligation continues to have an important role in the management of ethmoidal DAVFs 5.
Comparison of Treatment Options
- Surgical management has been shown to have a lower risk of complications, including visual loss, compared to endovascular treatment 2, 3.
- Endovascular treatment may be considered for well-selected cases with favorable arterial or venous access anatomy, but it is not always effective in achieving complete angiographic obliteration 3, 6.
- A multicenter experience and literature review suggest that both endovascular and surgical approaches can be effective in treating ethmoidal DAVFs, with complete angiographic obliteration achieved in 100% of cases immediately after treatment and at last follow-up evaluation 5.