Microsurgical management of cranial dural arteriovenous fistulas: Treating the "Sheep in Wolf's clothing"? - Three decades of experience and lessons learned.

Introduction: Cranial dural arteriovenous fistulas (dAVFs) are rare vascular lesions and a growing number are treated with endovascular techniques. However, drawing on over three decades of clinical experience, we contend that microsurgery continues to play a crucial role in the management of these lesions. Research question: This study aims to highlight the safety and efficacy of microsurgical treatment for dAVFs, while providing practical insights into technical considerations and potential pitfalls. Materials and methods: Medical records, imaging studies, and surgical reports of patients diagnosed with a dAVF and treated with microsurgery between 1990 and 2025 were reviewed. We evaluated presenting symptoms, location, surgical strategy, surgical complications, occlusion status, and associated morbidity. Additionally, four representative cases were selected to illustrate technical aspects of the procedure and intraoperative challenges. Results: Overall, 82 dAVFs were treated with microsurgery. Mean patient age was 60.1 years (SD ± 9.9 years) with a male predominance (60/22). Hemorrhagic presentation was observed in 49 % (40/82) of patients. The most common locations were the tentorium (40 %, 33/82), superior sagittal/transverse sinus (20 %, 16/82), convexity (13 %, 11/82), and anterior cranial fossa (13 %, 11/82). Complete occlusion was achieved in 89 % (73/82) of cases after the initial surgery. Surgical complications occurred in 10 % of cases (8/82), with procedure-related morbidity in 4 % (3/82). After additional treatment, the overall occlusion rate increased to 96 % (79/82). There were no surgery- or hemorrhage-related deaths, resulting in a mortality rate of 0 %. Discussion and conclusion: Microsurgery is an immediate, safe, and effective treatment option for dAVFs.