Masterclass #5: I am an osteodural vascular malformation: what does that mean? How do you treat me?

Edoardo BOCCARDI, Orlando M. DIAZ, Vitor MENDES PEREIRA, Jacques MORET, Laurent SPELLE

The management of osteodural vascular malformations are considered complex and are often ignored. To better understand how to treat them, in this Masterclass Professors Jacques Moret, Laurent Spelle and their expert panel begin by reviewing the anatomy of these AVMs followed by select cases which discuss strategies and illuminate management.

In considering these malformations:

• Is the type of venous drainage the only factor correlated with the neurological risk?
• As the osteodural malformation always drains into sinuses – how dangerous is the reflux from the sinuses to the cortical veins?
• When sinuses are visible, is it due to drainage from the cortical vein?
• Osteodural vascular malformations have a lower bleeding risk than leptomeningeal malformations – What are the Cognard classifications of each?

Does the risk inherent in these types of malformations justify the risk in treating them? A vein in hyper-pressure is more dangerous than an occluded vein. If treatment is chosen, would it be enough to occlude that vein?

A member of the expert panel says that in treating osteodural fistulas you spend 80% of the time understanding the situation, and 20% in treating it. Prof. Spelle adds, "Our anatomical understanding of the situation does not change the treatment philosophy. We know how to treat – we need to occlude the vein. We are aware of the danger of cerebral venous drainage…"

How do you treat? Follow the cases and discussion to learn why – and how – to approach the management of these complex AVMs…