Dural Arteriovenous Fistulas

What is a dural arteriovenous fistula?

A dural arteriovenous fistula (DAVF) is an abnormal connection between an artery and a vein within the tough outer covering of the brain (the dura mater). Unlike AVMs, DAVFs are usually acquired rather than congenital and can develop following trauma, venous thrombosis, or for unknown reasons.

DAVFs most commonly occur at the transverse, sigmoid, and cavernous sinuses. They are classified by the pattern of venous drainage, which determines the clinical risk and guides treatment decisions.

Symptoms

Symptoms depend on the location and type of DAVF. Common presentations include:

• Pulsatile tinnitus — a rhythmic whooshing sound in the ear, often the first symptom
• Orbital symptoms — redness, proptosis, or double vision (cavernous sinus fistulas)
• Headache
• Haemorrhage — intracranial bleeding if cortical venous drainage is present (high-risk pattern)
• Cognitive decline or focal neurological deficit in aggressive cases

Diagnosis

DAVFs are diagnosed using CT or MR angiography, but definitive characterisation requires catheter digital subtraction angiography (DSA), which provides the dynamic information needed to classify the fistula and plan treatment.

Treatment

Treatment is indicated for high-grade DAVFs (with cortical venous drainage or causing symptoms). Options include:

• Transarterial embolisation — injection of liquid embolic agent via the feeding artery
• Transvenous embolisation — coiling of the affected venous sinus
• Combined approach — often most effective
• Radiosurgery — for selected cases
• Neurosurgical disconnection — rarely required

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