====== Intracranial dural arteriovenous fistula surgery ======
While [[endovascular]] [[approach]]es have emerged as the primary [[treatment]] for most [[DAVF]]s, certain [[fistula]] types are still best dealt with via open surgery as the first line strategy
((Ashour R, Morcos JJ, Spetzler RF, et al. Surgical
Management of Cerebral Dural Arteriovenous
Fistulae. In: Comprehensive Management of
Arteriovenous Malformations of the Brain and
Spine. Cambridge: Cambridge University Press;
2015:144–170)). 

Furthermore, surgery has been used to successfully treat DAVFs after previous partial, incomplete, or failed [[endovascular treatment]]. Finally, surgery can be used adjunctively in a combined approach to provide direct access for [[embolization]] of DAVFs that are inaccessible by a purely endovascular route.

Preoperative embolization may facilitate surgical treatment
((Barnwell SL, Halbach VV, Higashida RT, et al.
Complex Dural Arteriovenous Fistulas: Results of
Combined Endovascular and Neurosurgical
Treatment in 16 Patients. J Neurosurg. 1989; 71:
352–358))
by lessening the risk of catastrophic hemorrhage, which may occur simply during the performance of the craniotomy
((Sundt TM, Piepgras DG. The Surgical Approach to
Arteriovenous Malformations of the Lateral and
Sigmoid Dural Sinuses. J Neurosurg. 1983; 59:
32–39)).

The use of the craniotome is discouraged, as a sinus or venous laceration could produce a fatal hemorrhage.
Contingencies for the rapid administration of blood products must be made (large bore central
lines). The scalp incision, craniotomy flap, and dural incision should be planned in a strategic manner
to control and sequentially eliminate the blood supply to the lesion at each step, while maximizing
the exposure as needed. 

Surgical options for the treatment of DAVFs include the following techniques
((Ashour R, Morcos JJ, Spetzler RF, et al. Surgical
Management of Cerebral Dural Arteriovenous
Fistulae. In: Comprehensive Management of
Arteriovenous Malformations of the Brain and
Spine. Cambridge: Cambridge University Press;
2015:144–170)):

1. radical fistula excision

2. sinus skeletonization

3. disconnection of cortical venous drainage

4. ligation of the fistulous point and/or outflow vein

5. sinus packing

6. coagulation of arterial feeders to the lesion

While surgery vs. endovascular treatment can be considered for all DAVF locations, two locations
generally remain more favorable for surgery:

1. anterior fossa/ethmoidal

2. tentorial DAVFs

The endovascular approach to these fistulas is difficult, whereas the surgical approach is often
straightforward. Surgically-assisted embolization, whereby a [[craniotomy]] is performed followed by
direct puncture for embolization of the target vessel, may be utilized in select cases.