An Intraoperative Look at a Residual/Recurrent Tentorial Dural Arteriovenous Fistula

Background: Dural arteriovenous fistulas (dAVFs) often are treated via transarterial or transvenous embolization. Incomplete penetration of the draining vein/occult residual often will become apparent on follow-up angiography, requiring repeat embolization, or at times, surgical resection.

Case description: A 41-year-old woman presented with cerebellar hemorrhage from a tentorial dAVF treated with transvenous coil embolization. Follow-up angiography disclosed a residual/recurrent fistula treated with transvenous Onyx embolization. After further follow-up angiography demonstrated another occult residual/recurrence, the fistula was disconnected with the tentorial dura excised via a retrosigmoid approach. Six-month follow-up angiography demonstrated no recurrence.

Conclusions: Although endovascular treatment of dAVFs is generally first-line therapy, surgical disconnection of fistulas, particularly high-risk residual/recurrent fistulas, is an excellent option in well-selected cases.