Intracranial Dural Arteriovenous Fistulas with Pial Arterial Supply

Neurosurgery. 2019 Jan 1;84(1):104-115. doi: 10.1093/neuros/nyy014.


Background: Pial arterial supplies are sometimes found in patients with dural arteriovenous fistulas (DAVFs), though their characteristics have rarely been clarified.

Objective: To investigate the characteristics of pial arterial supplies in DAVFs and to discuss their pathophysiology and treatment.

Methods: Two hundred four consecutive patients with intracranial DAVFs over 11 yr were retrospectively reviewed. Clinical factors and radiological findings, including the presence of pial arterial supplies, were evaluated. Supply from a pial artery was classified into 2 categories: dilated pre-existing dural branches of pial arteries, and a "pure" pial supply.

Results: Twenty-three of 204 patients (11.3%) showed an additional pial arterial supply. Multivariate analysis identified 3 independent predictors of a pial arterial supply: younger age (P < .0005), DAVF within the tentorium (P = .0162), and presence of venous dilatation (P = .0001). A dilated pre-existing dural branch of a pial artery was identified in 17 patients, while 8 had a pure pial supply. Of these 23 patients, 17 underwent interventional therapy. No postoperative intracranial hemorrhage or infarction occurred in patients with pial arterial supplies.

Conclusion: An additional pial supply is not uncommon in DAVFs and may be explained by a rich physiological pial arterial supply to the dura mater from the posterior circulation, while potential angiogenesis due to venous hypertension remains speculative. Prior to interventional treatment for DAVFs, recognition of a pial arterial supply to the DAVF might influence the treatment strategy and could help avoid inadvertent retrograde embolization of brain supplying vessels through the pial network.

MeSH terms

  • Central Nervous System Vascular Malformations* / diagnosis
  • Central Nervous System Vascular Malformations* / physiopathology
  • Cerebral Arteries* / diagnostic imaging
  • Cerebral Arteries* / physiopathology
  • Dura Mater / blood supply
  • Dura Mater / diagnostic imaging
  • Humans
  • Retrospective Studies