Journal of Neurosurgery 2026;145(2):424–435
Tentorial dural arteriovenous fistulas frequently have cortical venous drainage and an aggressive natural history. This international multicenter series focuses on microsurgery, often after embolization has failed. Tailored approaches achieved angiographic success in 90% with a low rate of permanent neurological morbidity. Results were similar whether surgery was the primary or salvage strategy. The study reinforces microsurgery as a durable option when endovascular cure is incomplete or anatomically unfavorable.
Objective
To describe surgical approaches, obliteration rates, complications and longer-term durability after microsurgical treatment of tentorial dural arteriovenous fistulas.
Methods
CONDOR retrospectively collected dural fistula data from 16 international centers between 1990 and 2021. Of 161 patients with a tentorial fistula, 44 underwent microsurgery; 23 received surgery as salvage treatment after failed embolization. Success required angiographically confirmed complete obliteration or, for a high-grade lesion, elimination of cortical venous drainage.
Main results
Aggressive presentation was present in 91% of the surgical cohort: 64% presented with hemorrhage and 27% with a nonhemorrhagic neurological deficit. The retrosigmoid approach was most common (44%), followed by midline suboccipital (24%) and occipital (15%) approaches.
Surgical success was achieved in 38 of 42 assessable patients (90%). Perioperative complications occurred in 11%, while permanent neurological deficit occurred in 2%. During a mean 3-year follow-up, 2 of 38 successfully treated fistulas (5%) recurred. Primary and salvage microsurgery had similar outcomes.
Interpretation
Microsurgery provides high and durable disconnection rates for tentorial fistulas that cannot be cured safely by embolization. The range of approaches reflects anatomical heterogeneity; operative planning should target the fistulous point and cortical venous outflow rather than apply a uniform exposure.
Limitations
This retrospective registry spans three decades, with substantial evolution in angiography, embolic agents and surgical practice. Only 44 patients underwent surgery, treatment selection was nonrandom and imaging follow-up was not necessarily uniform. Outcomes from experienced referral centers may not be reproduced in lower-volume units.
Clinical takeaway
Discuss high-grade tentorial dural fistulas in a multidisciplinary cerebrovascular team. When embolization cannot provide safe definitive disconnection—or has already failed—an anatomically tailored microsurgical approach offers a high likelihood of cure with acceptable morbidity in experienced hands.
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