Dural arteriovenous fistulas in the falx cerebri: case series and literature review

Dural arteriovenous fistulas in the falx cerebri: case series and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dural arteriovenous fistulas in the falx cerebri: case series and literature review Xin Su, Zihao Song, Ming YE, Liyong Sun, Tao Hong, Yongjie Ma, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4115548/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Dural arteriovenous fistulas (DAVFs) in the falx cerebri are seldomly reported. They may be associated with the falcine sinus/venous plexus. The falcine sinus/venous plexus is often considered a normal venous structure that manifests in a pathological state, different from the persistent fetal falcine sinus. Methods We performed a retrospective analysis at a single center, focusing on identifying all DAVFs in the falx cerebri between 2002 and 2022. Our study included the collection and analysis of data on demographics, fistula characteristics, treatment approaches, clinical outcomes, and fistula closure. In addition, we reviewed the literature on DAVFs in this area. Results Ten cases in our center and 13 cases of DAVFs in the falx cerevri reported in the literature were identified. At our center, the average age of the patients was 49.4 ± 8.1 years, and 90% were men. Trans-arterial embolization (TAE) alone resulted in immediate complete occlusion in eight cases. In two cases, conservative treatment was performed. There were no treatment-related complications or fistula recurrences found. According to the literature, seven patients underwent direct surgery, three underwent TAE, and one underwent both direct surgery and radiosurgery to completely close the fistula. There were no reported fistula recurrences or treatment complications. Conclusions Dural arteriovenous fistulas in the falx cerebri are rare, and there is limited literature available on this topic. Most of them are aggressive lesions. Curative treatment can be achieved by TAE or direct surgery. Further confirmation is needed to determine the involvement of the falcine sinus/venous plexus in falx cerebri DAVFs. Dural arteriovenous fistula Falcine sinus Falcine venous plexus Falx cerebri Hemorrhage Case series Figures Figure 1 Figure 2 INTRODUCTION Intracranial dural arteriovenous fistulas (DAVFs) are abnormal shunts between the dural arteries or pial arteries and dural venous sinus or cortical veins. They account for approximately 10–15% of all intracranial vascular malformations. 1,2 DAVFs are commonly located in the cavernous sinus, sigmoid/transverse sinus, superior sagittal sinus (SSS), anterior cranial fossa, tentorium and cranial cervical junction. 1–4 However, they are extremely rare in the falx cerebri/falcine sinus, and the majority of cases are treated surgically. 5–17 Here, we present the largest single-center case series treated by endovascular intervention and review the relevant literature. METHODS Study design This study was a retrospective analysis of 10 consecutive patients with DAVFs located in the falx cerebri, treated at a single institution from 2002 to 2022 with the approval of our hospital's ethics committee. All patients gave informed consent for their treatment. Clinical and radiographic information was gathered and summarized by 7 doctors (X.S, Z.S, M.Y, H.Z, Y.M, L.S, and P.Z). The study followed the PRCOESS guideline. 18 Data collection and definition Clinical data from patients, including medical records, operative reports, and angiographic information, were meticulously recorded and analyzed in this study. A variety of factors were considered, including age, gender, symptoms, angiographic results, treatment methods, outcomes, and any complications that occurred. Admissions, outpatient visits, and phone calls were employed to assess the patients’ post-treatment. Radiological assessments included magnetic resonance angiography (MRA) and digital subtraction angiography (DSA). The researchers evaluated the patients' functional status before, during, and after treatment using the modified Rankin Scale (mRS) score. The successful treatment was determined by achieving complete fistula closure and ensuring that the embolization materials reached the venous side. Pial arterial supplies were divided into two categories based on their morphological and anatomical characteristics. 19 The first group consisted of linear vessels that had dilated "physiological" pre-existing dural branches of pial arteries. 20 The second category included tortuous and ramified vessels discovered outside of the known physiological connections between pial arteries and the dura mater. This classification referred to the "pure pial supply" (Fig. 1). Treatment options Trans-arterial embolization (TAE) is typically the primary treatment choice. Balloon-assisted Onyx embolization might be employed to enhance the success rate of complete embolization. The Magic microcatheter (Balt, France) with Glubran2 (Gem, Italy) as the embolic agent, along with the Marathon or Headway microcatheter (Microvention, USA) using Onyx-18 (Medtronic, USA), were utilized. In certain scenarios, a dual-lumen balloon catheter (Scepter-C, Microvention, Tustin, California) was positioned near the fistula to facilitate Onyx casting for better penetration and to prevent Onyx reflux effectively. Bifrontal craniotomy was considered in cases where embolization was unsuccessful. When pure pial branches supplied the fistulas, they were usually first embolized using Glurbran to avoid intraoperative complications like intracranial hemorrhage. 21 Statistical analysis Continuous variables were presented as mean ± standard deviation, whereas categorical variables were described as frequencies and percentages. Results Patient and DAVF baseline characteristics The average age of the patients was 49.4 ± 8.1 (range, 33–62) years, and 90% (9/10) were men. Three patients presented with intracranial hemorrhage or subarachnoid hemorrhage (30%, 3/10). The most common symptoms were venous hyperdynamic symptoms (50%, 5/10) which included headache, dizziness and amaurosis. Two patients (20%, 2/10) were diagnosed with intracranial DAVF by chance due to intracranial artery stenosis. Two patients (20%, 2/10) had a significant history of head trauma. One patient (10%, 1/10) had multiple DAVFs located in the anterior cranial fossa, falx cerebri, tentorium and convexity. The median mRS score at presentation was 1 (IQR 1 to 2.25). In our series of angiograms, 8 (80%) patients had DAVFs involving the anterior portion of the falx cerebri and 2 patients had DAVFs involving the posterior portion of the falx cerebri. The middle meningeal artery (MMA) was the most common arterial feeder (90%, 9/10), followed by the ophthalmic artery (50%, 5/10), the anterior cerebral artery (ACA) (20%, 2/10), the occipital artery (20%, 2/10), the artery of Davidoff and Schechter (10%, 1/10) and the dural branch of the vertebral artery (10%, 1/10). Three cases of DAVF are supplied by the pial artery—two from the ACA and one from the posterior cerebral artery—amongst which one case receives "pure pial arterial supply" from the ACA (Fig. 1). The most common drainage veins typically include the falcine sinus (reported in literature), 12,13 which drains into the bridging veins, neighboring cortical veins, and the SSS (80%, 8/10) (Fig. 1). Additional drainage can be observed into the inferior sagittal sinus (ISS) and tributaries of the vein of Galen (Fig. 2). Seven patients (70%) had venous varices. Seven patients were classified as Cognard IV/Borden III, and three as Cognard III/Borden III. 1,2 Endovascular treatment and complication Eight patients with eight cerebri falx fistulas were primarily treated with TAE using liquid embolic agents and balloon. There were 10 embolization procedures. Immediate complete occlusion of the fistulas was achieved in all eight patients. The most common arterial route was MMA. Two patients refused further treatment after the detection of intracranial DAVF. There were no treatment-related complications. Follow-up Among 10 patients, 9 (90%) were followed-up either as inpatient, outpatient, or by telephone. No patients reported worsening symptoms. Seven patients had DSA and clinical follow-up from 4 months to 108 months. A patient underwent an MRA follow-up six months after complete occlusion. No recurrence of the fistula was found. Two patients who did not receive treatment, one of whom was lost to follow-up, while the other has remained asymptomatic for 112 months after the diagnosis of DAVF. The detailed baseline characteristics and outcomes of the 10 patients are summarized in Table 1 . Table 1 Summary of 10 cases of dural arteriovenous fistulas in the falx cerebri No. Age/Sex Presentation Disease duration Feeder Location Venous drainage Venous pouch Treatment Immediate Angiographic outcome Embolic material mRS Pre-operative Follow-up 1 42/M Headache 1 month MMA, PCA (ADS) Anterior FS?, corticle vein and SSS (+) TAE-MMA Complete occlusion Onyx 1 0 2 51/M Unrelated symptoms - MMA Anterior SSS via cortical vein (-) Conservative treatment - - 3 / 3 50/M ICH 13 days OphA, ACA (dural branch) Anterior FS?, corticle vein (+) TAE-OphA/ACA Complete occlusion Balloon-assisted Onyx/Glubran 4 0 4 50/M ICH 3 months MMA, OphA Anterior (Multiple) FS?, ISS (+) TAE- MMA Complete occlusion Onyx 1 0 5 53/M Unrelated symptoms - MMA Posterior Corticle vein and SSS (-) Conservative treatment - - 1 0 6 60/M Dizziness 6 months OA, MMA Posterior FS?, tributaries of the vein of Galen and itself, SS (-) TAE-OA Complete occlusion Onyx 1 0 7 62/F Headache 5 months OphA, MMA Anterior FS?, corticle vein and SSS (+) TAE-MMA Complete occlusion Onyx 1 0 8 33/M Amaurosis, dizziness 2 months MMA, OphA, ACA (pure pial supply) Anterior FS?, corticle vein and SSS (+) TAE-ACA/MMA Complete occlusion Glubran/Onyx 1 0 9 43/M SAH 20 hours MMA, OphA, dural branch of the VA, Anterior FS?, corticle vein and SSS (+) TAE-MMA Complete occlusion Onyx 2 1 10 50/M Dizziness 15 days MMA Anterior FS?, corticle vein and SSS (+) TAE-MMA Complete occlusion Onyx 1 1 ACA, anterior cerebral artery; ADS, the artery of Davidoff and Schechter; FS, falcine sinus; ICH, intracerebral hemorrhage; ISS, inferior sagittal sinus; MMA, middle meningeal artery; mRS, modified Rankin Scale; OA, occipital artery; OphA, ophthalmic artery; PCA, posterior cerebral artery; SAH, subarachnoid hemorrhage; SS, straight sinus; SSS, superior sagittal sinus; TAE, trans-arterial embolization; VA, vertebral artery; F, female; M, male; Literature review DAVF in the falx cerebri is extremely rare, with only a few cases reported (Table 2 ). 5–17 There were 13 reported cases, 11 of which had detailed baseline information and treatment-related information. The average age of the patients was 55.6 ± 15.2 (range, 24–73) years, and 75% (9/12) were men. Five patients presented with intracranial hemorrhage or subarachnoid hemorrhage (41.7%, 5/12). 10 (76.9%, 10/13) patients had DAVFs involving the anterior portion of the falx cerebri and 3 patients had DAVFs involving the posterior portion of the falx cerebri. Nine patients (69.2%, 9/13) had venous varices. To achieve complete closure of the fistula, seven patients (63.6%, 7/11) underwent direct surgery, three underwent TAE, and one underwent direct surgery plus radiosurgery. There were no reports of fistula recurrence or treatment-related complications. Table 2 Reported cases of dural arteriovenous fistulas in the falx cerebri No. Author, year Age/Sex Presentation Feeder Location Venous drainage Venous pouch Treatment Outcome 1 Pollock et al. (1968) 5 ?/? ICH AFA, MMA Anterior SSS (+) ? ? 2 Handa et al. (1973) 6 56/M SAH, coma, seizure AFA, ECA Anterior SSS via pial vein (-) Direct surgery Complete occlusion 3 Kosnik et al. (1974) 7 34/F Headache, seizure, nausea ACA, AFA, AMA Anterior ISS (-) Direct surgery Complete occlusion 4 Takaku et al. (1978) 8 34/M Headache, hemiparesis, motor aphasia OA, MTA, STA, AEA Anterior SSS via cortical vein (-) Direct surgery Complete occlusion 5 Agawa et al. (1991) 9 62/M SAH MMA, AFA Anterior SSS via dural vein/FS (+) Direct surgery Complete occlusion 6 Kothbauer et al. (1994) 10 73/F SAH MMA, OA Posterior Tributaries of the vein of Galen and itself (+) ? ? 7 Ratliff et al. (1999) 11 24/M Headache ACA, dural branch of the VA Anterior SSS, PPV and the vein of Galen (+) Direct surgery + radiosurgery Complete occlusion 8 Yoshioka et al. (2013) 12 60/M Incidental ACA, MMA, AEA Anterior FS, SSS and ISS (-) Direct surgery Complete occlusion 9 Yamaguchi et al. (2016) 13 67/M ICH ACA, MMA Anterior FS and SSS, PPV and the vein of Galen (+) TAE + direct surgery Complete occlusion 10 Koyanagi et al. (2016) 14 67/M Unrelated symptoms ACA, MMA Anterior Bridge vein and SSS (+) TAE Complete occlusion 11 Satoh et al. (2021) 15 59/M Incidental MMA, STA, OA, PMA Posterior Falcine venous plexus, corticle vein and SSS (+) TAE Complete occlusion 12 Yang et al. (2022) 16 69/M Seizure ACA, MMA Anterior FS, corticle vein and SSS (+) Direct surgery Complete occlusion 13 Diyora et al. (2023) 17 62/F Headache, gait ataxia MMA, VA, OA Posterior Corticle vein and SSS (+) TAE Complete occlusion ACA, anterior cerebral artery; AEA, anterior ethmoidal artery; AFA, anterior falx artery; AMA, anterior meningeal artery; ECA, external carotid artery; FS, falcine sinus; ICH, intracerebral hemorrhage; ISS, inferior sagittal sinus; MMA, middle meningeal artery; MTA, marginal tentorial artery; OA, occipital artery; PMA, posterior meningeal artery; PPV, posterior pericallosal vein; SAH, subarachnoid hemorrhage; SSS, superior sagittal sinus; STA, superficial temporal artery; TAE, trans-arterial embolization; VA, vertebral artery; F, female; M, male; Discussion A total of 23 cases of DAVFs in the falx cerebri including our cases has been reported (Tables 1 and 2 ), 21 of which had detailed baseline information and treatment-related information. 5–17 The average age of the patients was 52.8 ± 12.9 (range, 24–73), and 81.8% (18/22) were men. Eight patients presented with intracranial hemorrhage or subarachnoid hemorrhage (36.4%, 8/22). All of DAVFs are classified as high-grade types and often accompanied with venous pouch. DAVFs in the falcine sinus/venous plexus can be categorized as lateral epidural DAVFs. 12,13,22 They exhibit a severe clinical course, cortical venous reflux, and lack evidence of venous outflow obstruction, resembling anterior cranial base DAVFs. 3,22 DAVFs in the falx cerebri often receive arterial supply from the dural or pial branches of the ACA (34.8%, 8/23). Yoshioka et al. reported the only case in which the drainage vein of these DAVFs was identical to the falcine sinus/falcine venous plexus, but some cases could be judged to have falcine sinuses as part of their drainers. 12,13,15 Anatomic considerations The falcine sinus is a vascular structure that forms during embryonic development, connecting the SSS and ISS, typically closing after birth. 23 Yoshioka et al. reported a case of DAVF in the falx cerebri associated with the anterior falcine sinus. 12 Instances of persistent falcine sinus have been documented, while the persistence of the anterior falcine sinus is rare. The anterior falcine sinus establishes a connection between the SSS and ISS, offering an alternate pathway for venous drainage from the frontal lobes of the brain. 24 The falcine sinus may potentially act as a venous plexus. 25,26 It plays an important role in the vascular network that surrounds the falx cerebri and eventually transforms into the falcine sinus. 12,25–27 In the study by Yoshioka et al., observations during surgery and examination of the surgical sample showed a minor vascular structure within the falx cerebri connecting to the falcine sinus and ISS, likely indicative of a falcine venous plexus. 12 Satoh et al. described a rare case of DAVF in flax with a prominent falcine venous plexus that drained into a dilated corticle vein and was successfully treated with TAE. 15 However, Yang et al. failed to identify the falcine sinus in both the DSA and the surgical field. 16 The venous drainage converged in a venous pouch before entering the left frontoparietal leptomeningeal venous and, finally, the SSS. 16 In our case, due to the lack of surgical specimens, we had to rely solely on literature to determine the presence of the falcine sinus/venous plexus from DSA (Figs. 1 and 2). A persistent falcine sinus is a rare occurrence often observed in pediatric patients, frequently found alongside various anomalies. These anomalies may involve a bifid cranium, vein of Galen aneurysmal malformation, agenesis of the corpus callosum, Apert syndrome, osteogenesis imperfecta, as well as Chiari malformation Type II. 23 It is essential to differentiate between the rare persistent fetal falcine sinus and the falcine venous plexus. The sinus originates from mesenchyme in the mesencephalic flexure, where the straight sinus also forms. In cases where the straight sinus is absent or underdeveloped, the persistent falcine sinus may be recanalized. 27,28 The presence of a persistent falcine sinus without any accompanying anomalies is exceedingly rare. 26 The type of falcine venous plexus/falcine sinus observed in reported DAVF should not be considered a vascular anomaly, but consider that an embryonic vessel structure may become obvious with this abnormal circulation. 12,26 Treatment outcomes Based on literature reviews and our case series, DAVFs in this location are easily treated with a low rate of complications and recurrence (Tables 1 and 2 ; Figs. 1 and 2 ). 5–17 In contrast to the majority of the literature, all treated patients in our cases received TAE treatment and achieved the same therapeutic effects, resulting in lower trauma for the patients. Almost all DAVFs in the falx cerebri have straight MMA or occipital artery pathways, making TAE with Onyx to completely occlude the venous side a simple cure. Transvenous embolization is not feasible due to the difficulty in accessing and embolizing the venous side. Therefore, contrary to previous literature findings, with the continuous advancement of endovascular treatment, we consider TAE to be the primary treatment option for this type of DAVF, with direct surgery a secondary option. In the treatment of falx cerebri DAVF with pial arterial supply, common complications are related to intracranial hemorrhage or ischemic stroke. 19,21,29–32 The high risk of hemorrhage may be due to the lack of dural covering around the bridging vein fistula extending into the subdural space. The fragile glomus-like structures may rupture due to increased pressure after arterial embolization restricts venous drainage, similar to the principle observed in arteriovenous malformation embolization, in which feeding arteries rupture if the draining vein is completely occluded first. 33,34 The causes of ischemic stroke may be related to the reflux of embolic agents into the pial arteries or postoperative retrograde thrombosis of pial arteries, leading to cerebral ischemia. 31 These complications are more likely to occur in DAVFs with pure pial arterial supply. 32 Despite the controversy surrounding the treatment strategy for DAVFs with pial artery supply, we prefer to embolize the pure pial branches first, followed by the dural branches. Extensive removal of the falx cerebri, including the falcine sinus, the abnormal falcine venous plexus, and other draining veins, or complete endovascular obliteration of the entire draining system, is an effective strategy for treating them. 12,13 Study Limitations This study, being a single-center, retrospective analysis, is inherently limited. Some of these limitations include potential self-report bias and the lack of core laboratory adjudication. Furthermore, due to the wide time span covered in the literature review, it may not capture the current treatment status of DAVF in this location. Our case series also lacks surgical specimen, preventing confirmation of the existence of the falcine sinus/venous plexus. Conclusion Dural arteriovenous fistulas in the falx cerebri are rare, and there is limited literature available on this topic. Most of them are aggressive lesions. Curative treatment can be achieved by trans-arterial embolization or direct surgery. Further confirmation is needed to determine the involvement of the falcine sinus/venous plexus in falx cerebri dural arteriovenous fistulas. Abbreviations ACA, anterior cerebral artery; DAVF, dural arteriovenous fistula; DSA, digital subtraction angiography; IQR, interquartile range; ISS, inferior sagittal sinus; MMA, middle meningeal artery; MRA, magnetic resonance angiography; mRS, modified Ranking score; SSS, superior sagittal sinus; TAE, transarterial embolization; Declarations Ethical Approval This retrospective study involved human participants and was approved by Ethics Committee of Xuanwu Hospital, Capital Medical University [2017; 010]. Funding This study was funded by the National Natural Science Foundation of China (No.82101460). Availability of data and materials Data are available upon reasonable request. Authors’ contributions Conception and design: Xin Su, Peng Zhang. Acquisition of data: Xin Su, Zihao Song. Drafting the article: Xin Su. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4115548","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":281426621,"identity":"cb2f8c7f-4c55-4e4a-99e5-859d66a2744e","order_by":0,"name":"Xin Su","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Su","suffix":""},{"id":281426623,"identity":"4e5f90e1-ce43-4fb7-b368-29f5c9043034","order_by":1,"name":"Zihao Song","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zihao","middleName":"","lastName":"Song","suffix":""},{"id":281426624,"identity":"8a14811a-796b-49b0-b012-544fe535ec3f","order_by":2,"name":"Ming YE","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"YE","suffix":""},{"id":281426625,"identity":"57e779b1-2be7-48d4-a1ed-9b09094f5616","order_by":3,"name":"Liyong Sun","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Liyong","middleName":"","lastName":"Sun","suffix":""},{"id":281426626,"identity":"4a9e79a8-0319-4fb2-92ec-8fdb716b3999","order_by":4,"name":"Tao Hong","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Hong","suffix":""},{"id":281426627,"identity":"081edf09-243b-45aa-9685-b129e1c86154","order_by":5,"name":"Yongjie Ma","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yongjie","middleName":"","lastName":"Ma","suffix":""},{"id":281426628,"identity":"c2e223bd-e0b0-40e5-87f4-4d8de99de38c","order_by":6,"name":"Hongqi Zhang","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hongqi","middleName":"","lastName":"Zhang","suffix":""},{"id":281426629,"identity":"96f6c93a-4b80-4c3e-b178-31dbff49a276","order_by":7,"name":"Peng Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDACCQST8UFChQ1pWpgNHpxJI00Lm+TDtkOEdcjPbn728OsOmzz5iNxnFQlsBxj427sT8GphnHPM3Fj2TFqx4Y10sxsJPHcYJM6c3YBXC7NEgpm0ZNvhxI2z09huJEg8YzCQyMWvhU0i/RtQy3+wloIEg8OEtfBI5JhJfmw7kDhfOo2NISGBCC0SEjll0oxnkhM3yD8DOvJAGg9Bv8jPSN8m+XOHXeL8nmOMH3/+s5Hjb+/FrwUEmHkbGBgMDkBdSlA5CDD+BGqRbyBK7SgYBaNgFIxEAAD5rEoLHmjJVwAAAABJRU5ErkJggg==","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Peng","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-03-17 05:44:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4115548/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4115548/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53198795,"identity":"beb1f846-cfdc-44ca-a67b-056d3282d314","added_by":"auto","created_at":"2024-03-21 18:48:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3410263,"visible":true,"origin":"","legend":"\u003cp\u003eCase 8. (A-B) Right external carotid artery injection before embolization showed a dural arteriovenous fistula in the anterior portion of the falx cerebri mainly fed by the anterior falx artery from the middle meningeal artery. The fistula was drained by a venous pouch located in the falx cerebri (possibly the falcine sinus/venous plexus) (A, black arrows), an enlarged corticle vein (B, white arrow), and finally the superior sagittal sinus. (C-E) Internal carotid injection before embolization showed the fistula fed by the anterior ethmoidal artery from the ophthalmic artery and pure pial arterial supply from the callosomarginal artery (C, black arrow). A selective angiogram showed the tortuous pure pial arterial supply and Glubran was injected. (F-G) A selective angiogram of the middle meningeal artery and the fistula was completely occluded using Onyx. (H-J) Bilateral common carotid artery injection after 9 months of the treatment revealed no recurrence of the fistula.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4115548/v1/7765066222ff1ab62340506e.png"},{"id":53198796,"identity":"34fa4d51-a852-4e24-9f9b-0081a5fc5ea0","added_by":"auto","created_at":"2024-03-21 18:48:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3999784,"visible":true,"origin":"","legend":"\u003cp\u003eCase 5. (A-B) Right external carotid artery injection showed a dural arteriovenous fistula located in the posterior portion of the falx cerebri mainly fed by parietooccipital branch from the middle meningeal artery. The fistula point was identified in the falx cerebri (A, black arrow), with drainage into the parietal cortical vein (A-B, white arrow) and superior sagittal sinus.\u003c/p\u003e\n\u003cp\u003eCase 6. (C) Axial T2-MRI showed “flow void” sign along the interhemispheric fissure (black arrows). (D-F) Bilateral occipital artery injection showed a dural arteriovenous fistula located in the posterior portion of the falx cerebri with tributaries of the vein of Galen (D-E, white arrows), the vein of Galen and straight sinus drainage (D, blue arrows). Note the fistula point in the falx cerebri (possibly around the falcine sinus) (E, black arrow). (G) A selective angiogram of the middle meningeal artery. (H-K) The fistula was completely occluded using Onyx via the occipital artery.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4115548/v1/b0810aa203f35eb00ad98fe2.png"},{"id":53199407,"identity":"87788925-0761-4c93-a1df-d8328b500dbf","added_by":"auto","created_at":"2024-03-21 18:56:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1353822,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4115548/v1/aee54e25-e804-48e3-ba69-c9f872227ee5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dural arteriovenous fistulas in the falx cerebri: case series and literature review","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIntracranial dural arteriovenous fistulas (DAVFs) are abnormal shunts between the dural arteries or pial arteries and dural venous sinus or cortical veins. They account for approximately 10\u0026ndash;15% of all intracranial vascular malformations.\u003csup\u003e1,2\u003c/sup\u003e DAVFs are commonly located in the cavernous sinus, sigmoid/transverse sinus, superior sagittal sinus (SSS), anterior cranial fossa, tentorium and cranial cervical junction.\u003csup\u003e1\u0026ndash;4\u003c/sup\u003e However, they are extremely rare in the falx cerebri/falcine sinus, and the majority of cases are treated surgically.\u003csup\u003e5\u0026ndash;17\u003c/sup\u003e Here, we present the largest single-center case series treated by endovascular intervention and review the relevant literature.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e This study was a retrospective analysis of 10 consecutive patients with DAVFs located in the falx cerebri, treated at a single institution from 2002 to 2022 with the approval of our hospital's ethics committee. All patients gave informed consent for their treatment. Clinical and radiographic information was gathered and summarized by 7 doctors (X.S, Z.S, M.Y, H.Z, Y.M, L.S, and P.Z). The study followed the PRCOESS guideline.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection and definition\u003c/h2\u003e \u003cp\u003eClinical data from patients, including medical records, operative reports, and angiographic information, were meticulously recorded and analyzed in this study. A variety of factors were considered, including age, gender, symptoms, angiographic results, treatment methods, outcomes, and any complications that occurred. Admissions, outpatient visits, and phone calls were employed to assess the patients\u0026rsquo; post-treatment. Radiological assessments included magnetic resonance angiography (MRA) and digital subtraction angiography (DSA). The researchers evaluated the patients' functional status before, during, and after treatment using the modified Rankin Scale (mRS) score.\u003c/p\u003e \u003cp\u003eThe successful treatment was determined by achieving complete fistula closure and ensuring that the embolization materials reached the venous side. Pial arterial supplies were divided into two categories based on their morphological and anatomical characteristics.\u003csup\u003e19\u003c/sup\u003e The first group consisted of linear vessels that had dilated \"physiological\" pre-existing dural branches of pial arteries.\u003csup\u003e20\u003c/sup\u003e The second category included tortuous and ramified vessels discovered outside of the known physiological connections between pial arteries and the dura mater. This classification referred to the \"pure pial supply\" (Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTreatment options\u003c/h2\u003e \u003cp\u003eTrans-arterial embolization (TAE) is typically the primary treatment choice. Balloon-assisted Onyx embolization might be employed to enhance the success rate of complete embolization. The Magic microcatheter (Balt, France) with Glubran2 (Gem, Italy) as the embolic agent, along with the Marathon or Headway microcatheter (Microvention, USA) using Onyx-18 (Medtronic, USA), were utilized. In certain scenarios, a dual-lumen balloon catheter (Scepter-C, Microvention, Tustin, California) was positioned near the fistula to facilitate Onyx casting for better penetration and to prevent Onyx reflux effectively. Bifrontal craniotomy was considered in cases where embolization was unsuccessful.\u003c/p\u003e \u003cp\u003eWhen pure pial branches supplied the fistulas, they were usually first embolized using Glurbran to avoid intraoperative complications like intracranial hemorrhage.\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, whereas categorical variables were described as frequencies and percentages.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient and DAVF baseline characteristics\u003c/h2\u003e \u003cp\u003eThe average age of the patients was 49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1 (range, 33\u0026ndash;62) years, and 90% (9/10) were men. Three patients presented with intracranial hemorrhage or subarachnoid hemorrhage (30%, 3/10). The most common symptoms were venous hyperdynamic symptoms (50%, 5/10) which included headache, dizziness and amaurosis. Two patients (20%, 2/10) were diagnosed with intracranial DAVF by chance due to intracranial artery stenosis. Two patients (20%, 2/10) had a significant history of head trauma. One patient (10%, 1/10) had multiple DAVFs located in the anterior cranial fossa, falx cerebri, tentorium and convexity. The median mRS score at presentation was 1 (IQR 1 to 2.25).\u003c/p\u003e \u003cp\u003eIn our series of angiograms, 8 (80%) patients had DAVFs involving the anterior portion of the falx cerebri and 2 patients had DAVFs involving the posterior portion of the falx cerebri. The middle meningeal artery (MMA) was the most common arterial feeder (90%, 9/10), followed by the ophthalmic artery (50%, 5/10), the anterior cerebral artery (ACA) (20%, 2/10), the occipital artery (20%, 2/10), the artery of Davidoff and Schechter (10%, 1/10) and the dural branch of the vertebral artery (10%, 1/10). Three cases of DAVF are supplied by the pial artery\u0026mdash;two from the ACA and one from the posterior cerebral artery\u0026mdash;amongst which one case receives \"pure pial arterial supply\" from the ACA (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eThe most common drainage veins typically include the falcine sinus (reported in literature),\u003csup\u003e12,13\u003c/sup\u003e which drains into the bridging veins, neighboring cortical veins, and the SSS (80%, 8/10) (Fig.\u0026nbsp;1). Additional drainage can be observed into the inferior sagittal sinus (ISS) and tributaries of the vein of Galen (Fig.\u0026nbsp;2). Seven patients (70%) had venous varices. Seven patients were classified as Cognard IV/Borden III, and three as Cognard III/Borden III.\u003csup\u003e1,2\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEndovascular treatment and complication\u003c/h2\u003e \u003cp\u003eEight patients with eight cerebri falx fistulas were primarily treated with TAE using liquid embolic agents and balloon. There were 10 embolization procedures. Immediate complete occlusion of the fistulas was achieved in all eight patients. The most common arterial route was MMA. Two patients refused further treatment after the detection of intracranial DAVF. There were no treatment-related complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up\u003c/h2\u003e \u003cp\u003eAmong 10 patients, 9 (90%) were followed-up either as inpatient, outpatient, or by telephone. No patients reported worsening symptoms. Seven patients had DSA and clinical follow-up from 4 months to 108 months. A patient underwent an MRA follow-up six months after complete occlusion. No recurrence of the fistula was found. Two patients who did not receive treatment, one of whom was lost to follow-up, while the other has remained asymptomatic for 112 months after the diagnosis of DAVF. The detailed baseline characteristics and outcomes of the 10 patients are summarized in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of 10 cases of dural arteriovenous fistulas in the falx cerebri\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge/Sex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePresentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDisease duration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFeeder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVenous drainage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVenous pouch\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eImmediate Angiographic outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEmbolic material\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003emRS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003ePre-operative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA, PCA (ADS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS?, corticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE-MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOnyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnrelated symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSSS via cortical vein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eConservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eICH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOphA, ACA (dural branch)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS?, corticle vein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE-OphA/ACA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eBalloon-assisted Onyx/Glubran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eICH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA, OphA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior (Multiple)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS?, ISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE- MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOnyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnrelated symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCorticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eConservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOA, MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS?, tributaries of the vein of Galen and itself, SS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE-OA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOnyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62/F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOphA, MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS?, corticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE-MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOnyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmaurosis, dizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA, OphA, ACA (pure pial supply)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS?, corticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE-ACA/MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eGlubran/Onyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSAH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA, OphA, dural branch of the VA,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS?, corticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE-MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOnyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS?, corticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE-MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOnyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eACA, anterior cerebral artery; ADS, the artery of Davidoff and Schechter; FS, falcine sinus; ICH, intracerebral hemorrhage; ISS, inferior sagittal sinus; MMA, middle meningeal artery; mRS, modified Rankin Scale; OA, occipital artery; OphA, ophthalmic artery; PCA, posterior cerebral artery; SAH, subarachnoid hemorrhage; SS, straight sinus; SSS, superior sagittal sinus; TAE, trans-arterial embolization; VA, vertebral artery;\u003c/p\u003e \u003cp\u003eF, female; M, male;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLiterature review\u003c/h2\u003e \u003cp\u003eDAVF in the falx cerebri is extremely rare, with only a few cases reported (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003csup\u003e5\u0026ndash;17\u003c/sup\u003e There were 13 reported cases, 11 of which had detailed baseline information and treatment-related information. The average age of the patients was 55.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2 (range, 24\u0026ndash;73) years, and 75% (9/12) were men. Five patients presented with intracranial hemorrhage or subarachnoid hemorrhage (41.7%, 5/12). 10 (76.9%, 10/13) patients had DAVFs involving the anterior portion of the falx cerebri and 3 patients had DAVFs involving the posterior portion of the falx cerebri. Nine patients (69.2%, 9/13) had venous varices. To achieve complete closure of the fistula, seven patients (63.6%, 7/11) underwent direct surgery, three underwent TAE, and one underwent direct surgery plus radiosurgery. There were no reports of fistula recurrence or treatment-related complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReported cases of dural arteriovenous fistulas in the falx cerebri\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAuthor, year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge/Sex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePresentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFeeder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVenous drainage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVenous pouch\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePollock et al. (1968)\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e?/?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eICH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAFA, MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHanda et al. (1973)\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSAH, coma, seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAFA, ECA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSSS via pial vein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDirect surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKosnik et al. (1974)\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34/F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeadache, seizure, nausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eACA, AFA, AMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDirect surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTakaku et al. (1978)\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeadache, hemiparesis, motor aphasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOA, MTA, STA, AEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSSS via cortical vein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDirect surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgawa et al. (1991)\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSAH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA, AFA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSSS via dural vein/FS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDirect surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKothbauer et al. (1994)\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73/F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSAH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA, OA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTributaries of the vein of Galen and itself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRatliff et al. (1999)\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eACA, dural branch of the VA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSSS, PPV and the vein of Galen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDirect surgery\u0026thinsp;+\u0026thinsp;radiosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoshioka et al. (2013)\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncidental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eACA, MMA, AEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS, SSS and ISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDirect surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYamaguchi et al. (2016)\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eICH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eACA, MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS and SSS, PPV and the vein of Galen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE\u0026thinsp;+\u0026thinsp;direct surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKoyanagi et al. (2016)\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnrelated symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eACA, MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBridge vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSatoh et al. (2021)\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncidental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA, STA, OA, PMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFalcine venous plexus, corticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYang et al. (2022)\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eACA, MMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFS, corticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDirect surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiyora et al. (2023)\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62/F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeadache, gait ataxia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMMA, VA, OA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCorticle vein and SSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTAE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplete occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eACA, anterior cerebral artery; AEA, anterior ethmoidal artery; AFA, anterior falx artery; AMA, anterior meningeal artery; ECA, external carotid artery; FS, falcine sinus; ICH, intracerebral hemorrhage; ISS, inferior sagittal sinus; MMA, middle meningeal artery; MTA, marginal tentorial artery; OA, occipital artery; PMA, posterior meningeal artery; PPV, posterior pericallosal vein; SAH, subarachnoid hemorrhage; SSS, superior sagittal sinus; STA, superficial temporal artery; TAE, trans-arterial embolization; VA, vertebral artery;\u003c/p\u003e \u003cp\u003eF, female; M, male;\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eA total of 23 cases of DAVFs in the falx cerebri including our cases has been reported (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), 21 of which had detailed baseline information and treatment-related information.\u003csup\u003e5\u0026ndash;17\u003c/sup\u003e The average age of the patients was 52.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9 (range, 24\u0026ndash;73), and 81.8% (18/22) were men. Eight patients presented with intracranial hemorrhage or subarachnoid hemorrhage (36.4%, 8/22). All of DAVFs are classified as high-grade types and often accompanied with venous pouch. DAVFs in the falcine sinus/venous plexus can be categorized as lateral epidural DAVFs.\u003csup\u003e12,13,22\u003c/sup\u003e They exhibit a severe clinical course, cortical venous reflux, and lack evidence of venous outflow obstruction, resembling anterior cranial base DAVFs.\u003csup\u003e3,22\u003c/sup\u003e DAVFs in the falx cerebri often receive arterial supply from the dural or pial branches of the ACA (34.8%, 8/23). Yoshioka et al. reported the only case in which the drainage vein of these DAVFs was identical to the falcine sinus/falcine venous plexus, but some cases could be judged to have falcine sinuses as part of their drainers.\u003csup\u003e12,13,15\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAnatomic considerations\u003c/h2\u003e \u003cp\u003eThe falcine sinus is a vascular structure that forms during embryonic development, connecting the SSS and ISS, typically closing after birth.\u003csup\u003e23\u003c/sup\u003e Yoshioka et al. reported a case of DAVF in the falx cerebri associated with the anterior falcine sinus.\u003csup\u003e12\u003c/sup\u003e Instances of persistent falcine sinus have been documented, while the persistence of the anterior falcine sinus is rare. The anterior falcine sinus establishes a connection between the SSS and ISS, offering an alternate pathway for venous drainage from the frontal lobes of the brain.\u003csup\u003e24\u003c/sup\u003e The falcine sinus may potentially act as a venous plexus.\u003csup\u003e25,26\u003c/sup\u003e It plays an important role in the vascular network that surrounds the falx cerebri and eventually transforms into the falcine sinus.\u003csup\u003e12,25\u0026ndash;27\u003c/sup\u003e In the study by Yoshioka et al., observations during surgery and examination of the surgical sample showed a minor vascular structure within the falx cerebri connecting to the falcine sinus and ISS, likely indicative of a falcine venous plexus.\u003csup\u003e12\u003c/sup\u003e Satoh et al. described a rare case of DAVF in flax with a prominent falcine venous plexus that drained into a dilated corticle vein and was successfully treated with TAE.\u003csup\u003e15\u003c/sup\u003e However, Yang et al. failed to identify the falcine sinus in both the DSA and the surgical field.\u003csup\u003e16\u003c/sup\u003e The venous drainage converged in a venous pouch before entering the left frontoparietal leptomeningeal venous and, finally, the SSS.\u003csup\u003e16\u003c/sup\u003e In our case, due to the lack of surgical specimens, we had to rely solely on literature to determine the presence of the falcine sinus/venous plexus from DSA (Figs.\u0026nbsp;1 and 2).\u003c/p\u003e \u003cp\u003eA persistent falcine sinus is a rare occurrence often observed in pediatric patients, frequently found alongside various anomalies. These anomalies may involve a bifid cranium, vein of Galen aneurysmal malformation, agenesis of the corpus callosum, Apert syndrome, osteogenesis imperfecta, as well as Chiari malformation Type II.\u003csup\u003e23\u003c/sup\u003e It is essential to differentiate between the rare persistent fetal falcine sinus and the falcine venous plexus. The sinus originates from mesenchyme in the mesencephalic flexure, where the straight sinus also forms. In cases where the straight sinus is absent or underdeveloped, the persistent falcine sinus may be recanalized.\u003csup\u003e27,28\u003c/sup\u003e The presence of a persistent falcine sinus without any accompanying anomalies is exceedingly rare.\u003csup\u003e26\u003c/sup\u003e The type of falcine venous plexus/falcine sinus observed in reported DAVF should not be considered a vascular anomaly, but consider that an embryonic vessel structure may become obvious with this abnormal circulation.\u003csup\u003e12,26\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTreatment outcomes\u003c/h2\u003e \u003cp\u003eBased on literature reviews and our case series, DAVFs in this location are easily treated with a low rate of complications and recurrence (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; \u003cb\u003eFigs.\u0026nbsp;1 and 2\u003c/b\u003e).\u003csup\u003e5\u0026ndash;17\u003c/sup\u003e In contrast to the majority of the literature, all treated patients in our cases received TAE treatment and achieved the same therapeutic effects, resulting in lower trauma for the patients. Almost all DAVFs in the falx cerebri have straight MMA or occipital artery pathways, making TAE with Onyx to completely occlude the venous side a simple cure. Transvenous embolization is not feasible due to the difficulty in accessing and embolizing the venous side. Therefore, contrary to previous literature findings, with the continuous advancement of endovascular treatment, we consider TAE to be the primary treatment option for this type of DAVF, with direct surgery a secondary option.\u003c/p\u003e \u003cp\u003eIn the treatment of falx cerebri DAVF with pial arterial supply, common complications are related to intracranial hemorrhage or ischemic stroke.\u003csup\u003e19,21,29\u0026ndash;32\u003c/sup\u003e The high risk of hemorrhage may be due to the lack of dural covering around the bridging vein fistula extending into the subdural space. The fragile glomus-like structures may rupture due to increased pressure after arterial embolization restricts venous drainage, similar to the principle observed in arteriovenous malformation embolization, in which feeding arteries rupture if the draining vein is completely occluded first.\u003csup\u003e33,34\u003c/sup\u003e The causes of ischemic stroke may be related to the reflux of embolic agents into the pial arteries or postoperative retrograde thrombosis of pial arteries, leading to cerebral ischemia.\u003csup\u003e31\u003c/sup\u003e These complications are more likely to occur in DAVFs with pure pial arterial supply.\u003csup\u003e32\u003c/sup\u003e Despite the controversy surrounding the treatment strategy for DAVFs with pial artery supply, we prefer to embolize the pure pial branches first, followed by the dural branches.\u003c/p\u003e \u003cp\u003eExtensive removal of the falx cerebri, including the falcine sinus, the abnormal falcine venous plexus, and other draining veins, or complete endovascular obliteration of the entire draining system, is an effective strategy for treating them.\u003csup\u003e12,13\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eThis study, being a single-center, retrospective analysis, is inherently limited. Some of these limitations include potential self-report bias and the lack of core laboratory adjudication. Furthermore, due to the wide time span covered in the literature review, it may not capture the current treatment status of DAVF in this location. Our case series also lacks surgical specimen, preventing confirmation of the existence of the falcine sinus/venous plexus.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDural arteriovenous fistulas in the falx cerebri are rare, and there is limited literature available on this topic. Most of them are aggressive lesions. Curative treatment can be achieved by trans-arterial embolization or direct surgery. Further confirmation is needed to determine the involvement of the falcine sinus/venous plexus in falx cerebri dural arteriovenous fistulas.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eACA, anterior cerebral artery; DAVF, dural arteriovenous fistula; DSA, digital subtraction angiography; IQR, interquartile range; ISS, inferior sagittal sinus; MMA, middle meningeal artery; MRA, magnetic resonance angiography; mRS, modified Ranking score; SSS, superior sagittal sinus; TAE, transarterial embolization;\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthical Approval\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study involved human participants and was approved by Ethics Committee of Xuanwu Hospital, Capital Medical University [2017; 010].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the National Natural Science Foundation of China (No.82101460).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design: Xin Su, Peng Zhang. Acquisition of data: Xin Su, Zihao Song. Drafting the article: Xin Su. Critically revising the article: Yongjie Ma, Ming Ye, Liyong Sun, Tao Hong, Peng Zhang, Hongqi Zhang. All of the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eDisclosure of interests:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003enone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003enone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCognard C, Gobin YP, Pierot L, et al. Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. \u003cem\u003eRadiology\u003c/em\u003e. Mar 1995;194(3):671-80. doi:10.1148/radiology.194.3.7862961\u003c/li\u003e\n\u003cli\u003eBorden JA, Wu JK, Shucart WA. 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Endovascular Management of Falcine Dural Arteriovenous Fistula-A Case Report and Review of Literature. \u003cem\u003eAsian J Neurosurg\u003c/em\u003e. Dec 2023;18(4):818-822. doi:10.1055/s-0043-1776302\u003c/li\u003e\n\u003cli\u003eAgha RA, Sohrabi C, Mathew G, Franchi T, Kerwan A, O\u0026apos;Neill N. The PROCESS 2020 Guideline: Updating Consensus Preferred Reporting Of CasESeries in Surgery (PROCESS) Guidelines. \u003cem\u003eInt J Surg\u003c/em\u003e. Dec 2020;84:231-235. doi:10.1016/j.ijsu.2020.11.005\u003c/li\u003e\n\u003cli\u003eOsada T, Krings T. Intracranial Dural Arteriovenous Fistulas with Pial Arterial Supply. \u003cem\u003eNeurosurgery\u003c/em\u003e. Jan 1 2019;84(1):104-115. doi:10.1093/neuros/nyy014\u003c/li\u003e\n\u003cli\u003eBhogal P, Makalanda HL, Brouwer PA, et al. Normal pio-dural arterial connections. \u003cem\u003eInterventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences\u003c/em\u003e. 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Nov-Dec 2000;24(6):343-8. doi:10.1016/s0895-6111(00)00031-8\u003c/li\u003e\n\u003cli\u003eMatouk CC, Mandell DM, Krings T, Willinsky RA, Ter Brugge KG. Persistant anterior falcine sinus: demonstration by CT angiography. \u003cem\u003eThe Canadian journal of neurological sciences Le journal canadien des sciences neurologiques\u003c/em\u003e. Sep 2011;38(5):760-1. doi:10.1017/s0317167100054159\u003c/li\u003e\n\u003cli\u003eRyu CW. Persistent falcine sinus: is it really rare? \u003cem\u003eAJNR Am J Neuroradiol\u003c/em\u003e. Feb 2010;31(2):367-9. doi:10.3174/ajnr.A1794\u003c/li\u003e\n\u003cli\u003eTubbs RS, Loukas M, Louis RG, Jr., et al. Anatomy of the falcine venous plexus. \u003cem\u003eJ Neurosurg\u003c/em\u003e. Jul 2007;107(1):155-7. doi:10.3171/jns-07/07/0155\u003c/li\u003e\n\u003cli\u003eStrub WM, Leach JL, Tomsick TA. Persistent falcine sinus in an adult: demonstration by MR venography. \u003cem\u003eAJNR Am J Neuroradiol\u003c/em\u003e. Apr 2005;26(4):750-1.\u003c/li\u003e\n\u003cli\u003eKesava PP. Recanalization of the falcine sinus after venous sinus thrombosis. \u003cem\u003eAJNR Am J Neuroradiol\u003c/em\u003e. Oct 1996;17(9):1646-8.\u003c/li\u003e\n\u003cli\u003eBrinjikji W, Cloft HJ, Lanzino G. Clinical, angiographic, and treatment characteristics of cranial dural arteriovenous fistulas with pial arterial supply. \u003cem\u003eJ Neurointerv Surg\u003c/em\u003e. Apr 2021;13(4):331-335. doi:10.1136/neurintsurg-2020-016374\u003c/li\u003e\n\u003cli\u003eSato K, Matsumoto Y, Endo H, Tominaga T. A hemorrhagic complication after Onyx embolization of a tentorial dural arteriovenous fistula: A caution about subdural extension with pial arterial supply. \u003cem\u003eInterv Neuroradiol\u003c/em\u003e. Jun 2017;23(3):307-312. doi:10.1177/1591019917694839\u003c/li\u003e\n\u003cli\u003eHetts SW, Yen A, Cooke DL, et al. Pial Artery Supply as an Anatomic Risk Factor for Ischemic Stroke in the Treatment of Intracranial Dural Arteriovenous Fistulas. \u003cem\u003eAJNR Am J Neuroradiol\u003c/em\u003e. Dec 2017;38(12):2315-2320. doi:10.3174/ajnr.A5396\u003c/li\u003e\n\u003cli\u003eMiyamoto N, Naito I. Analysis of the Pial Arterial Supply as a Cause of Intraprocedural Hemorrhage During Transarterial Liquid Embolization of Tentorial Dural Arteriovenous Fistulas. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. Jul 2022;163:e283-e289. doi:10.1016/j.wneu.2022.03.105\u003c/li\u003e\n\u003cli\u003eAlbuquerque FC, Ducruet AF, Crowley RW, Bristol RE, Ahmed A, McDougall CG. Transvenous to arterial Onyx embolization. \u003cem\u003eJ Neurointerv Surg\u003c/em\u003e. May 2014;6(4):281-5. doi:10.1136/neurintsurg-2012-010628\u003c/li\u003e\n\u003cli\u003eChoudhri O, Ivan ME, Lawton MT. Transvenous Approach to Intracranial Arteriovenous Malformations: Challenging the Axioms of Arteriovenous Malformation Therapy? \u003cem\u003eNeurosurgery\u003c/em\u003e. Oct 2015;77(4):644-51; discussion 652. doi:10.1227/neu.0000000000000869\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Dural arteriovenous fistula, Falcine sinus, Falcine venous plexus, Falx cerebri, Hemorrhage, Case series","lastPublishedDoi":"10.21203/rs.3.rs-4115548/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4115548/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDural arteriovenous fistulas (DAVFs) in the falx cerebri are seldomly reported. They may be associated with the falcine sinus/venous plexus. The falcine sinus/venous plexus is often considered a normal venous structure that manifests in a pathological state, different from the persistent fetal falcine sinus.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe performed a retrospective analysis at a single center, focusing on identifying all DAVFs in the falx cerebri between 2002 and 2022. Our study included the collection and analysis of data on demographics, fistula characteristics, treatment approaches, clinical outcomes, and fistula closure. In addition, we reviewed the literature on DAVFs in this area.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTen cases in our center and 13 cases of DAVFs in the falx cerevri reported in the literature were identified. At our center, the average age of the patients was 49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1 years, and 90% were men. Trans-arterial embolization (TAE) alone resulted in immediate complete occlusion in eight cases. In two cases, conservative treatment was performed. There were no treatment-related complications or fistula recurrences found. According to the literature, seven patients underwent direct surgery, three underwent TAE, and one underwent both direct surgery and radiosurgery to completely close the fistula. There were no reported fistula recurrences or treatment complications.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDural arteriovenous fistulas in the falx cerebri are rare, and there is limited literature available on this topic. Most of them are aggressive lesions. Curative treatment can be achieved by TAE or direct surgery. Further confirmation is needed to determine the involvement of the falcine sinus/venous plexus in falx cerebri DAVFs.\u003c/p\u003e","manuscriptTitle":"Dural arteriovenous fistulas in the falx cerebri: case series and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-21 18:48:27","doi":"10.21203/rs.3.rs-4115548/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-05-07T17:34:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-27T21:37:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270772481818133554671154999593586747324","date":"2024-04-27T19:46:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-26T08:02:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"03006b8f-c9fc-4808-836f-5b734785418c","date":"2024-03-25T12:33:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b6fb92fe-86e7-4424-b53a-373fa1e73906","date":"2024-03-25T02:11:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f6a317f3-0038-446c-b25b-07c893dd12e1","date":"2024-03-24T18:18:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326f3336-c59a-455a-aa22-684a93ae7d34","date":"2024-03-24T18:08:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-24T17:45:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-24T17:44:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-19T14:45:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2024-03-17T05:38:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5fe6b949-6f5a-4348-9664-ca681003166b","owner":[],"postedDate":"March 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-24T02:10:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-21 18:48:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4115548","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4115548","identity":"rs-4115548","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}