Intracranial dural arteriovenous fistula: a comprehensive review of the history, management, and future prospective

Dural arteriovenous fistulas (DAVF) are abnormal acquired intracranial vascular malformations consisting of pathological connections located within the dura between the pial arteries and the veno vasora, comprising the walls of the dural sinuses, bridging veins, or transosseous emissary veins. Dural arteriovenous fistulas are distinguished from arteriovenous malformations by their arterial supply from the vessels that perfuse the dura mater and lack of a parenchymal nidus. They are most commonly situated at the transverse and cavernous sinuses. The mechanism of development behind dural arteriovenous fistula can be explained by the molecular and anatomical factors. Multiple classification systems have been proposed throughout history including; Djindjian and Merland, Cognard, and Borden classification systems. The aggressiveness of the clinical course in intracranial dural arteriovenous fistula can be predicted through the angiographic patterns of venous drainage, more specifically, the presence of cortical venous drainage, the presence of venous ectasia, and the aggressiveness of clinical presentation. Intracranial dural arteriovenous fistulas might be discovered incidentally. However, if symptomatic, the clinical presentation ranges from mild neurological deficits to severe, lethal intracranial hemorrhage. Angiography is the imaging of choice to investigate, diagnose, and plan treatment for intracranial dural arteriovenous fistula. The management algorithm of intracranial dural arteriovenous fistula can be broadly divided into conservative, surgical, endovascular, and/or radiosurgical options. With the advent of endovascular therapies, surgery has fallen out of favor for managing intracranial dural arteriovenous fistulas. In the present article, the pathophysiology, classifications, natural history, clinical manifestations, radiological features, management, and complications are comprehensively reviewed.