Complications of Therapies for Dural Arteriovenous Fistulas in Children

Surgical

As with any surgical intervention, DAVF surgeries have risks. In addition to hemorrhage, infection, CSF leaks, and seizures, there are some specific threats inherent to redirecting cerebral blood flow in DAVFs, including:

• Neurological deficits due thrombosis of normal venous outflow and venous infarction: In addition to the common surgical complications, venous infarction can develop if normal venous drainage is accidentally interrupted. It is important to preserve normal drainage to the brain. A thorough study of preoperative imaging is vital to avoid this complication.
• Cranial nerve palsies: Ligation of feeding arteries, especially if very proximal, could theoretically damage cranial nerves, as a significant part of their vascularization originates from dural branches.
• Massive blood loss: This is especially important in infants, who have smaller hemodynamic reserves to offset the loss.
• Hydrocephalus: Hydrocephalus is not a common complication. Monitor for signs of high ICP and rule out intraventricular hemorrhage. An external ventricular drain might be necessary to temporarily control hydrocephalus.
• Normal perfusion pressure breakthrough: This is less frequent than with AVMs, which derive more flow from the pial arterial supply. In fistulas that recruit significant pial supply and cause associated arterial steal phenomena, swelling and neurological deficit can appear after blood flow is redirected to chronically vasodilated normal pial vessels after treatment. Tight blood pressure control is key to control this phenomenon.
• Recurrence and progression: DAVFs are dynamic lesions. They can recur even if posttreatment imaging shows no active shunting.

Medical

• Decompensation of heart function: This could range from increased fatigue to pulmonary edema.

Other

Radiation

• Radiation injury during endovascular treatment: Radiation exposure from multiple long-term embolization sessions can cause permanent injury to the brain or the scalp.
• Radiation injury from radiosurgery: Up to 10% of patients experience radiation-associated injury after radiosurgery. This can manifest in many different ways, from focal deficits to cognitive impairment. The impacts may be temporary or permanent and typically occur in a delayed fashion (33). Additionally, after radiation therapy, there is a low risk of developing secondary malignancies of the brain (33).