Cerebral dural arteriovenous fistulae presenting with acute hemorrhage: a systematic review

•High grade dAVFs have increased hemorrhage risk, requiring urgent care and complete obliteration.•Endovascular treatments are more common, but surgeries show higher rates of complete obliteration and lower recurrence.•Surgery is preferred when endovascular treatment is inadequate or limited by multiple arterial feeders or thrombotic occlusion.•Both approaches have potential complications, emphasizing the need for a multidisciplinary approach and structured follow-up. Cerebral dural arteriovenous fistulae (dAVFs) are rare connections between arteries and veins or sinuses in the brain. dAVFs have a higher risk of intracranial hemorrhages due to increased venous pressure. Endovascular treatment is considered the first line treatment. However, it is unknown if surgery improves outcomes for patients presenting with an acute hemorrhage. Therefore, this systematic review assesses complete obliterations and recurrences of surgery and endovascular treatment in hemorrhagic dAVFs patients. A literature search in the PubMed and Web of Sciences database was conducted up till October 2021. Studies of surgical and endovascular treatments with hemorrhagic dAVFs were included. The Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group and the JBI critical appraisal checklist for case reports were used for risk of bias assessment. Eleven articles were included. 681 dAVFs patients with 686 fistulae were reported. 245 (36%) patients presented with an intracranial hemorrhage. Most fistulae were found in the transverse or sigmoid sinuses (n =220; 32.1%) and the majority were classified as Borden III. 571 endovascular treatments resulted in 390 (68.3%) complete dAVF obliterations and there was a recurrence of 66 dAVFs (16.9%). 183 surgeries resulted in the complete obliteration of 166 fistulae (91.8%) with a recurrence of 2 dAVFs (1.2%). Due to the lack of literature on hemorrhagic dAVFs exclusively, we cannot make a statement on the effectiveness of surgical interventions compared to endovascular treatments. Future studies should report outcomes based on location, previous treatments, and patient presentation.