Endovascular Treatment of Intracranial Dural Arteriovenous Fistulas Presenting with Intracranial Hemorrhage in 46 Consecutive Patients: With Emphasis on Transarterial Embolization with Onyx

The purpose of this study was to evaluate the effectiveness and safety as well as the clinical and angiographic results of endovascular treatment (EVT) for patients with hemorrhagic dural arteriovenous fistulas (DAVFs). From April 2009 to November 2013, 46 consecutive patients (7 women, 39 men; mean age, 46.7 years) diagnosed with hemorrhagic intracranial DAVFs at our department were enrolled in this study. Clinical and angiographic data were reviewed and evaluated. Two fistulas were cured by transvenous approach, and all other fistulas were embolized through transarterial route. After treatment with last embolization, a residual shunt was observed in 15 patients, including near-total obliteration of the fistula in 6 patients (13.0 %) and partial obliteration of the fistula in 9 patients (19.6 %). Seven of them underwent supplementary Gamma knife surgery. Complications occurred during or after EVT in six patients. One patient died 10 days after EVT because of complications of Onyx embolus into the posterior inferior cerebellar artery. Other complications included microcatheter entrapment in one case, trigeminocardiac reflex in one, facial nerve paresis in two, and occulomotor nerve paresis in one. The facial nerve paresis in one patient markedly improved but did not completely resolve during follow-up period. The other four patients recovered well, without symptoms at clinical follow-up. Angiographic follow-up result was obtained in 35 cases, with complete obliteration in 27 of them (77.1 %). Clinical follow-up outcomes were good, with 38 patients (82.6 %) reporting modified Rankin Scale of either 0 or 1. No patient suffered recurrent intracranial hemorrhage during follow-up. EVT was effective and safe in the modern management of ruptured intracranial DAVFs, with complete cure in most lesions. Clinical outcomes were good despite patients presenting with intracranial hemorrhage.