BRAIN INTERVENTIONAL Dural Arteriovenous Fistulas: Review of Imaging Findings and Endovascular Treatment Strategies Jeffrey A. Haithcock, G. Lee Pride ABSTRACT This article aims to review the imaging diagnosis and endovascular treatment of DAVFs. Case examples are used to present characteristic noninvasive and invasive diagnostic imaging find- ings. Important treatment considerations that assist in planning and implementing appropriate endovascular treatment are reviewed. Educational objectives of the article include the ability to readily identify and describe the multimodality imaging findings present in intracranial and spinal DAVFs and to discuss various endovascular treatment strategies, including transarterial approaches, transvenous approaches, and combined surgical/endovascular therapy. INTRODUCTION DAVFs are complex lesions frequently associ- ated with nonspecific clinical symptoms. Pulsa- tile tinnitus may strongly suggest a diagnosis, but other common symptoms of headache, fo- cal neurologic signs, or cognitive difficulties are less suggestive, contributing to delay in diagno- sis. An accurate timely diagnosis requires a high degree of suspicion coupled with awareness of specific sometimes subtle findings on noninva- sive imaging examinations. Recognition of these findings allows a presumptive diagnosis, but these examinations may provide insuffi- cient information for appropriate classification and treatment planning; thus, invasive DSA is often required. Endovascular treatment of DAVFs evolved and matured rapidly during the past few decades. Current endovascular techniques allow curative treatment in many cases, moving catheter-based paradigms to the forefront of fistula treatment. 1,2 APPROACH/METHODS We reviewed case material from our endo- vascular practice to identify cases that il- lustrate characteristic imaging findings and successful endovascular treatment of intra- cranial or spinal DAVFs. The diagnostic imaging examinations reviewed include MR imaging, CT, and catheter-based diag- nostic DSA examinations. DIAGNOSTIC AND TREATMENT CONSIDERATIONS History The initial descriptions of DAVF and subse- quent definition in the literature paralleled the development and maturation of cerebral and spinal angiography. Although there were early case reports from the 1930s, the idea of spontaneous DAVFs was introduced in the 1950s. 3 In later years, classification systems were proposed enabling prediction of behavior based on venous drainage. 4-6 Two of the most useful classification schemes are those proposed by Borden et al 4 and Cog- nard et al. 5 The development of endovascu- lar techniques significantly impacted the treatment of these lesions, such that endovas- cular treatment is now one of the most com- mon forms of treatment. 1,2,7-10 Pathophysiology/Anatomy Cranial DAVFs represent abnormal vascu- lar connections between a dural venous si- ABBREVIATIONS KEY: DAVF = dural arteriovenous fistula DSA = digital subtraction angiography Received February 2, 2011; accepted after revision March 29. From Department of Radiology, Division of Neuroradiology, UT Southwestern Medical Center at Dallas, Dallas, Texas Please address correspondence to Jeffrey A. Haithcock, MD, UT Southwestern Medical Center at Dallas, Division of Neuroradiology, 5323 Harry Hines Blvd, Dallas, TX 75390; e-mail: j-allan@sbcglobal.net DOI 10.3174/ng.1110006 Neurographics 01:31–38 June 2011 www.neurographics.com | 31