Dural Arteriovenous Fistula Treatment

Written and medically reviewed by Brian Walcott, MD, board-certified neurosurgeon at Santa Barbara Cottage Hospital. Last updated September 2026.

Understanding Dural Arteriovenous Fistulas

A dural arteriovenous fistula (DAVF) is an abnormal connection between arteries and veins inside the dura, the tough membrane that covers the brain and spinal cord. Normally, blood passes from arteries through a network of tiny capillaries before it reaches the veins. In a fistula, arterial blood flows directly into a vein or into one of the large venous channels, called sinuses, that drain the brain. Those veins are not built for arterial pressure.

Unlike brain arteriovenous malformations, which are generally thought to form early in life, most dural fistulas develop during adulthood. Some follow a blood clot in a venous sinus, a head injury, or prior surgery, but in many patients no cause is ever found.

The most important question with any fistula is where the blood drains. When a fistula drains only into a venous sinus in the normal direction, it is often low risk and may mainly cause bothersome symptoms, such as a pulsing sound in the ear. When it drains backward into the veins on the surface of the brain, called cortical venous drainage, the risk of hemorrhage, seizures, and neurologic decline is substantially higher, and treatment is usually recommended. Grading systems such as the Borden and Cognard classifications are built around this distinction.

My Approach to Dural AV Fistulas

Dural fistulas are uncommon, their anatomy varies enormously from patient to patient, and the right treatment depends on details that are only visible on a catheter angiogram. I review each patient's angiogram in detail. Because I trained in both endovascular neurosurgery and open cerebrovascular surgery, I can recommend the approach that best fits the fistula rather than the one technique a single specialist happens to perform.

The goal of treatment is to close the fistula completely at the exact point where the artery meets the vein. When that point is completely closed, the fistula is usually cured. Partial treatment is rarely enough when there is cortical venous drainage, so my goal is complete closure whenever it can be achieved safely. Every treatment carries risks, including stroke and bleeding, which I review with you in detail beforehand. Patients who have been told their fistula is too complex to treat are welcome to request a second opinion.

Treatment Options

Endovascular Embolization

Most fistulas today are treated from inside the blood vessels. Through a small puncture in an artery, usually in the groin or wrist, I guide a microcatheter to the fistula and fill the connection with a liquid embolic agent, which solidifies and seals it. Some fistulas are best reached through a vein instead, called transvenous embolization, in which the diseased segment of vein is closed from within. Many patients go home the next day.

Microsurgical Disconnection

Some fistulas, such as those along the floor of the front of the skull or along the tentorium, can be difficult or risky to reach with a catheter. In these locations, surgery to disconnect the draining vein where it leaves the dura is often the most direct and durable cure.

Stereotactic Radiosurgery

For select fistulas that cannot be safely treated with embolization or surgery, focused radiation can gradually close the connection over one to three years. Because protection is not immediate, radiosurgery is generally reserved for lower-risk fistulas.

Observation

Fistulas without cortical venous drainage and with tolerable symptoms can often be followed safely with periodic imaging. I monitor symptoms closely, because a fistula can occasionally change its drainage pattern over time. If the whooshing sound changes or suddenly stops, or you develop new neurologic symptoms, contact my office promptly.

Symptoms of a Dural AV Fistula

• Pulsatile tinnitus: a whooshing sound in time with your heartbeat
• Headaches
• Eye redness, bulging, double vision, or vision changes, when the fistula is near the eye (carotid-cavernous fistula)
• Seizures
• Weakness, numbness, speech difficulty, or changes in memory and thinking
• Sudden severe headache from bleeding in the brain

If you experience a sudden severe headache, new weakness, or difficulty speaking, call 911 immediately.

Why Choose Dr. Walcott for Dural AV Fistula Treatment?

• Endovascular and Open Expertise: Fellowship training in endovascular neurosurgery (USC) and open cerebrovascular surgery (UCSF), so every option is on the table
• Liquid Embolic Experience: Experience with liquid embolic agents, the workhorse of modern fistula embolization
• Harvard and MGH Residency: Neurosurgical training at Massachusetts General Hospital and Harvard Medical School
• Comprehensive Stroke Center: Treatment and neurocritical care at Santa Barbara Cottage Hospital
• Academic Excellence: Author of over 160 peer-reviewed publications, many in cerebrovascular disease