Background: Dural arteriovenous fistulas (dAVF) are abnormal anastomoses between meningeal arteries and dural venous sinuses and have a yearly incidence rate of 0.15 to 0.29 patients per 100,000 people. Typically, dAVF treatment involves an endovascular or microsurgical approach. A hybrid approach combining endovascular and microsurgical treatment, however, may improve patient outcomes. Few reports of hybrid approaches to dAVF embolization are available, thus, we hope to add to the literature with this case report to support this less explored surgical approach.
Case Presentation: We present the case of a female in her late 60s who presented for headaches. Angiography revealed an extensive superior sagittal sinus dAVF with multiple bilateral arterial feeders, including the superficial temporal artery, the occipital artery and the middle meningeal artery. The fistula involved the superior sagittal sinus with cortical venous drainage. Parts of the sinus around the middle third were thrombosed. Initial attempts at coiling were incomplete due to complicated venous access, however, a second surgery using a hybrid
approach resulted in successful obliteration of the dAVF. Eight months post-operatively, she reports improved personality and irritability symptoms, but continued headaches and blurry vision.
Discussion: Cerebrovascular procedures in hybrid rooms have already been widely described in the literature, however this technology is not available in every neurosurgical center and has been mostly used in the treatment of cerebral aneurysm. This case report exemplifies the potential benefit of a hybrid approach in treating high grade (Cognard class IIa and IIb in this case) dAVFs. With more case reports and large-scale clinical studies examining patient outcomes, the hybrid surgical technique may offer promising prognoses to future patients with complex dAVFs.

Treatment of a dural arteriovenous fistulas (dAVF) in a hybrid surgical setting:

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