Dural arteriovenous fistulas in neurosurgical practice: from clinical suspicion to curative treatment

Abstract

A cranial dural arteriovenous fistula is a vascular malformation where meningeal arteries connect directly to dural or cortical veins. It can occur at any age and may cause hemorrhages and severe neurological deficits. Early diagnosis and accurate classification are essential for the optimal approach. To review the imaging, diagnostic, and therapeutic aspects of dural arteriovenous fistulas (dAVFs), highlighting the role of the multidisciplinary team in their management. A systematic literature review was conducted using PubMed, Scopus, and Web of Science databases, covering the period from 2010 to 2025. Original studies, metaanalyses, and relevant guidelines on the diagnosis, classification, and treatment of dural fistulas were included. Fistulas are most frequently located in the transverse and sigmoid sinuses. Clinical risk assessment uses the Cognard and Borden classifications. Definitive diagnosis is made by angiography, which also aids in treatment planning. The fistula’s location, flow, angioarchitecture, and drainage help predict clinical outcome. Treatment is based on symptoms and the risk of hemorrhage or intracranial hypertension. Endovascular therapy with ONYX is effective in over 85% of cases, and fistulas with retrograde cortical drainage require prompt intervention. There is no clear consensus on managing asymptomatic fistulas. Dural arteriovenous fistulas are rare and lack universal guidelines. Early diagnosis and personalized treatment, especially endovascular, can prevent severe complications. A multidisciplinary approach is essential for timely diagnosis and effective management.