Zerebrale durale arteriovenöse Fisteln

Zerebrale dAVF (durale arteriovenöse Fisteln) können asymptomatisch sein, aber auch schwere neurologische Defizite verursachen. Die Therapieentscheidung erfordert deshalb genaue Kenntnisse dieser Malformationen. Die vorliegende Arbeit beschreibt das Erscheinungsbild der intrakraniellen dAVF in Klinik und Bildgebung, beleuchtet die zu einer dAVF führenden Pathomechanismen und geht auf Indikationen und Möglichkeiten der Therapie ein.

Abstract

Dural arteriovenous fistulas (DAVF), also referred to as dural arteriovenous malformations, account for 10 – 15 % of all intracranial vascular malformations with AV-shunt. DAVF are pathologic shunts between dural arteries and dural venous sinuses, meningeal or cortical veins. Most frequently, DAVF are located within the wall of the transverse, sigmoid, cavernous, sagittal superior sinus or within the cerebellar tentorium. Whereas in many cases no underlying pathomechanism is found, thrombosis of venous vessels, inflammatory processes and trauma have been listed as underlying causes. Depending on localization of the fistula, shunt volume, and venous drainage pattern, the clinical presentation of patients ranges from asymptomatic to severe neurological deficits. Dural AVF can be graded using the classifications of Cognard et al. or Borden et al., both of which stratify the lesions with special emphasis on venous drainage patterns, as cortical venous drainage has been found to be associated with an increased risk for intracranial haemorrhage. The indication to treat a DAVF thus mainly depends on the patients’ clinical presentation as well as the venous drainage pattern. Carotid cavernous fistulas likewise are DAVF, but since more frequently they are traumatic, they are categorized according to Barrow et al. Treatment options include (transvenous and/or transarterial) endovascular approaches, neurosurgery, and radiosurgery. A combination of the afore- mentioned treatment modalities is feasible. Thus, treatment of DAVF should be performed in a neurovascular center with close interdisciplinary cooperation of a team of neuroradiologists, neurosurgeons, and radiotherapists and neurologists.

Kernaussagen

• Die dAVF macht ca. 10 – 15 % aller intrakraniellen vaskulären Malformationen mit AV-Shunt aus. Es handelt sich um einen Kurzschluss zwischen Arterien und Venen unter Umgehung des regulären Kapillarbetts mit dem Fistelpunkt in der Dura mater. Am häufigsten betroffen sind die Sinus transversus, sigmoideus, cavernosus und sagittalis superior sowie das Tentorium.

• Als Pathomechanismen werden vor allem Thrombosen venöser Blutleiter, entzündliche Prozesse und Traumata aufgeführt, wobei häufig auch keine der vorgenannten zugrunde liegenden Erkrankungen nachweisbar ist.

• In Abhängigkeit von Fistellokalisation, Shunt-Volumen und Drainagemuster reicht das klinische Spektrum von asymptomatisch bis hin zu schwersten neurologischen Defiziten.

• Die dAVF werden meist nach Cognard u. Mitarb. oder Borden u. Mitarb. klassifiziert. Beide Klassifikationen berücksichtigen vor allem die venöse Drainage, die das Blutungsrisiko bestimmt. Als Sonderfall ist die CCF zu betrachten, die nach Barrow u. Mitarb. klassifiziert wird.

• Bei dAVF handelt es sich um eine interdisziplinär von Neuroradiologen, Neurochirurgen, Neurologen und Strahlentherapeuten zu behandelnde Erkrankung.

• Eine Behandlungsindikation leitet sich vor allem aus dem venösen Drainagemuster ab, das das Blutungsrisiko bedingt, sowie aus den klinischen Symptomen.

• Die Behandlungsoptionen beinhalten ein isoliertes oder kombiniertes endovaskuläres, neurochirurgisches und radiochirurgisches Vorgehen mit dem Ziel der Ausschaltung der Fistel. Das entsprechende Vorgehen ist primär der Anatomie und der Klassifizierung der dAVF anzupassen.

Schlüsselwörter

Zerebrale durale arteriovenöse Fistel - Klassifikation - Pathomechanismus - Bildgebung - Therapie

Keywords

cerebral dural arteriovenous fistula - classifications - pathomechanism - imaging techniques - therapy

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