Hybrid surgery for refractory intracranial dural arteriovenous fistula: A retrospective cohort study

Background Endovascular treatment is a first-line therapeutic strategy for most intracranial dural arteriovenous fistulas (DAVFs). However, for refractory DAVFs treated via inaccessible transarterial and transvenous routes, the obliteration rate is extremely low. To overcome these challenges, we performed combined surgical and endovascular treatment in a hybrid operating suite. Materials and methods This retrospective cohort study enrolled patients with refractory DAVFs who underwent combined direct surgical access to the target vessel and embolization in a hybrid operating suite between September 2018 and September 2024. The baseline demographic, clinical and radiological features, surgical techniques and outcomes were collected and analyzed. Results A total of 12 patients (mean ± SD age 53.2 ± 10.8 years, range 39–68 years) were included in this study. Three patients presented with intracranial bleeding, and 9 had venous hypertension-related symptoms. The fistulas included cortical DAVFs in 3 patients, cavernous sinus DAVFs in 6 patients, tentorial DAVFs in 2 patients and torcular DAVFs in 1 patient. The Borden and Cognard DAVF classifications included high-grade DAVFs in all 12 patients (Borden type II + III, Cognard IIb, IIa + b, IV). Direct surgical access to the feeding artery, draining vein and sinus was achieved in 6, 4 and 2 patients, respectively. Among the 12 patients, 8 underwent craniotomy, 3 underwent orbital surgery, and 1 underwent endoscopic surgery. The cohort demonstrated 100% immediate obliteration of refractory DAVFs without complications. At the six-month follow-up, all the patients experienced symptom improvement without fistula recurrence. Conclusions These findings revealed that hybrid surgery was a safe and effective treatment for refractory DAVFs.