Intracranial dural arteriovenous fistulas with and without pial arterial supply: a case series of 227 patients.

BACKGROUND: Intracranial dural arteriovenous fistulas (DAVFs) with pial arterial supply (PAS) constitute a distinct subgroup characterized by more complex angioarchitecture and potential implications for treatment planning. This study evaluated the incidence, angiographic characteristics, and clinical predictors of PAS in a cohort of patients with DAVFs. METHODS: This retrospective study included 227 consecutive patients with intracranial DAVF treated at our institution. Clinical and imaging data were reviewed and analyzed to characterize DAVF angioarchitecture and determine the presence of PAS. RESULTS: A total of 227 patients with DAVFs were included, and PAS was identified in 44 patients (19.4%). DAVFs with PAS were more frequently located at the cerebral convexity and tentorium than DAVFs without PAS. In addition, DAVFs with PAS were associated with higher angiographic grades and greater venous dilation. Clinical presentation rates were comparable between the two groups. Fistulas with PAS were more often managed with endovascular treatment. Microsurgery and hybrid surgery may represent effective treatment options in selected patients with complex DAVFs such as DAVFs located in the anterior cranial fossa (ACF) or foramen magnum (FM). Rates of surgical disconnection or hybrid surgery were similar between the two groups. Compared with DAVFs without PAS, DAVFs with PAS had significantly lower complete obliteration rates. Major complication rates, including postoperative ICH and cerebral infarction, were similar between the groups. CONCLUSION: DAVFs with PAS are associated with higher angiographic grades and increased venous dilation. DAVFs with PAS pose unique therapeutic challenges, as reflected by lower complete obliteration rates. Nevertheless, with careful technique and appropriate surgical strategies, major complication rates can be comparable to those of DAVFs without PAS.