Management of Dural Arteriovenous Fistulas in Children

Initial Management at Presentation

• Varies with age: Treatment strategies for DAVF depend on the age and type of lesion involved. A multidisciplinary team of neurosurgeons and neuroradiologists should develop an individualized approach.
• Watch and wait: Asymptomatic DAVFs, especially Borden type I, can be observed. In symptomatic cases (ie, patients with chronic disabling tinnitus), treatment can be considered.
• Treat signs of venous hypertension: Patients showing cortical venous reflux and variceal veins, particularly if symptomatic, should be treated with endovascular procedures, open surgery, or a combination of both (31). In general, endovascular procedures are the first-line treatment (11). Nevertheless, some locations, such as ethmoidal and tentorial DAVFs, might be more suitable for open surgical treatment. Radiosurgery might also play a role in select cases (32,33).

Adjunctive Therapies

• Stereotactic radiosurgery: This is a treatment option reserved for children with low-risk DAVFs without venous reflux. The effect of radiosurgery is delayed (up to 36 months), and obliteration rates of 55% to 80% have been reported (33). Side effects, such as compromise to cognitive development and, rarely, tumor formation, should be strongly considered and discussed with the parents before indicating radiosurgery in children (32,33).

Follow-up

• Surveillance: As these lesions often recur, especially if partially treated, establish a serial imaging follow-up plan, such as every 6 months for the first year and yearly after that for an additional 5 years (34). It is generally advisable to start with noninvasive imaging (such as TOF MRA and MRI with contrast) and to continue with conventional angiography if the clinical and noninvasive studies suggest recurrence.
• Recurring symptoms: Perform imaging if symptoms recur.