Management of Petrous and Tentorial Dural Arteriovenous Fistulas: A Systematic Review.

The petrous and tentorial dural arteriovenous fistulas are vascular malformations that are very infrequent but highly aggressive, with a significant risk of intracranial hemorrhage and neurological deficits. Optimal management remains one of the most debated subjects, with various series reporting endovascular and microsurgical approaches. Therefore, this systematic review aims to assess the efficacy, safety, and outcomes of different treatment modalities of petrous and tentorial dural arteriovenous fistulas (DAVFs) based on clinical presentation, imaging techniques, treatment outcome, and complications arising in the course of their treatment. A systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was carried out, which aimed to identify literature regarding both petrous and tentorial DAVFs. Major databases, including PubMed and Scopus, are searched using various related terms. Patient demographics as well as clinical presentations of patients with petrous and tentorial DAVFs were abstracted concerning imaging modalities, approaches adopted for their treatment, and the eventual outcome. The quality of studies was assessed using the Newcastle-Ottawa Scale, and data were synthesized through descriptive analysis. A total of 14 studies involving 198 patients were included. The mean patient age ranged from 38 to 59.8 years, with a male predominance (78%). Clinical presentations varied from headaches and tinnitus to life-threatening intracranial hemorrhage. Digital subtraction angiography (DSA) was the gold standard for diagnosis, while MRI and CT were useful adjuncts in assessing hemorrhage and venous drainage. Endovascular embolization using Onyx achieved complete obliteration in the majority of cases, though recurrence was noted in fistulas with complex arterial supply. Microsurgical approaches, particularly in cases where endovascular treatment was insufficient, demonstrated high cure rates with low recurrence. Complications included cranial nerve palsies and, in rare cases, arterial or venous rupture. Mortality was low, with a case fatality rate of 0%-15.4% across the studies. Both endovascular and microsurgical treatments are effective for managing petrous and tentorial DAVFs, though microsurgery provides superior results in complex or recurrent cases. A combination of embolization and surgery offers the best chance for durable fistula obliteration. Early diagnosis and individualized treatment plans guided by advanced imaging are critical for optimizing patient outcomes.