Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience

Mohamed M. Salem, Visish M. Srinivasan, Daniel A. Tonetti, Krishnan Ravindran, Philipp Taussky, Kaiyun Yang, Katherine Karahalios, Kunal P. Raygor, Ryan M. Naylor, Joshua S. Catapano, Samon Tavakoli-Sabour, Ahmed Abdelsalam, Stephanie H. Chen, Ramesh Grandhi, Brian T. Jankowitz, Mustafa K. Baskaya, Justin R. Mascitelli, Jamie J. Van Gompel, Jacob Cherian, William T. CouldwellLouis J. Kim, Aaron A. Cohen-Gadol, Robert M. Starke, Peter Kan, Amir R. Dehdashti, Adib A. Abla, Michael T. Lawton, Jan Karl Burkhardt

Research output: Contribution to journalArticlepeer-review


BACKGROUND: Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports. OBJECTIVE: To report a multicenter experience assessing microsurgery safety/efficacy. METHODS: Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021). RESULTS: Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%. CONCLUSION: Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.

Original languageEnglish (US)
Pages (from-to)205-212
Number of pages8
Issue number1
StatePublished - Jan 1 2023
Externally publishedYes


  • Clip
  • Craniocervical
  • Ligation
  • Microsurgery
  • dAVF

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery


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