Cranial base approaches for the surgical treatment of aggressive posterior fossa dural arteriovenous fistulae with leptomeningeal drainage: report of four technical cases

Dural arteriovenous fistulae (DAVFs) with leptomeningeal drainage have an aggressive natural history. Urgent treatment is necessary to arrest neurological deterioration and to prevent the risk of intracranial hemorrhage. In many patients, a primary endovascular approach is the most appropriate and most successful treatment available. In some circumstances, however, surgical intervention is required for complete obliteration. Posterior fossa DAVFs are generally deep-seated and difficult to gain access to with standard surgical approaches. The advent of cranial base surgery allows 360-degree access to the draining venous complex or sinus via extradural bone removal. Four patients with posterior fossa DAVFs presented to the neurosurgical service at our institutions. One DAVF was located at the craniocervical junction, and three were tentorial DAVFs of the superior petrosal sinus. All four patients were treated surgically with extradural bone removal. Postoperative angiography documented complete obliteration of all four DAVFs. All patients had normal recoveries, with the exception of one patient who experienced persistent temporal lobe seizure activity as a result of the presenting hematoma. One patient died of unrelated causes 2 years after surgery. One postoperative temporal lobe hematoma required evacuation. Recent advances in cranial base techniques have allowed the successful obliteration of aggressive posterior fossa DAVFs with acceptable morbidity. The use of these techniques should be considered in selected patients who cannot be treated with endovascular approaches.