Department of  Neurosurgery
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Arteriovenous Fistula

Arteriovenous fistulas (AVFs) are abnormal connections between blood vessels in the coverings of the brain. The word arteriovenous refers to the direct connection between arteries and veins, and the medical term fistula indicates that two things are connected that should not be connected.

Although some rare AVFs appear in newborns, this type of abnormality typically develops as people grow older and is not considered hereditary (passed on through families) or congenital (present at birth) . 

Washington University cerebrovascular surgeons work as part of a multidisciplinary team to offer treatment for arteriovenous fistulas at the Barnes-Jewish Hospital Stroke and Cerebrovascular Center. The Center is among the most experienced in managing brain vascular malformations and receives physician referrals from across the country. 

In addition to cerebrovascular surgeons, other physician members of the treatment team include neurologists who specialize in interventional radiology; critical care and neuro-rehabilitation neurologists; and radiation oncologists, who perform Gamma Knife radiosurgery. AVFs are not cancerous, but radiation oncologists can use radiosurgery to treat them.


People who have an AVF often experience no symptoms at all and are diagnosed by chance. Others visit a physician when problems appear, and an AVF is discovered at that time.

An AVF causes four main types of symptoms:

Tinnitus: The most common symptom of an AVF is an unusual sound in one or both ears, called tinnitus. Although many patients describe it as a rushing or whooshing noise, it sometimes occurs as a high-pitched ringing, buzzing, hissing, humming or whistling sound.

Eye symptoms: Some patients develop eye difficulties including pain behind the eye, bulging of the eye, decreased vision, double vision, drooping of the eyelid and swelling of the eye itself. These symptoms typically are caused by an AVF located behind or near the eye.

Brain hemorrhage: Certain patients can develop symptoms due to bleeding into the brain, resulting in a hemorrhagic stroke. Patients at risk are those who have an AVF that drains blood directly into veins of the brain — a condition called cortical venous drainage (CVD). Symptoms suggestive of brain hemorrhage include sudden-onset headache, nausea, vomiting, weakness or numbness on one side of the body, difficulties with making or understanding speech, loss of vision, double vision and balance difficulties. People experiencing any of these symptoms should seek medical help immediately. Brain hemorrhage is a serious form of stroke that can cause brain injury and even death, although many patients make good long-term recoveries.

Other symptoms: Patients whose AVFs drain blood into veins of the brain (CVD) also can develop seizures, memory loss, and symptoms similar to a stroke, including weakness/numbness on one side of the body, difficulties in speaking or understanding speech, loss of vision, double vision and balance difficulties.


AVFs are treated on a case-by-case basis. Treatment options include

  • Observation
  • Endovascular embolization
  • Surgery 
  • Gamma Knife radiosurgery

The type of treatment depends on the AVF’s location, presence or absence of cortical venous drainage (CVD), severity and nature of symptoms, the patient’s age and health status, and the risk involved in treatment. 

When a patient has an AVF without CVD, observation is often the appropriate choice. It may also be appropriate for select patients who have an AVF with CVD, including those who are older, have multiple medical problems or have a complex AVF for which treatment carries high risk.

Endovascular Embolization
This inpatient procedure entails passing a small catheter (tube) from a blood vessel in the groin (or arm) up into the AVF, where glue or other material is injected. For many patients, this cures the AVF; in others, it is used in preparation for surgery or radiosurgery. If successful, it provides immediate protection against AVF rupture.


Open surgery is an inpatient procedure designed to remove the CVD (the dangerous part of an AVF) or cure the entire AVF. If successful, the procedure provides immediate protection against AVF rupture.

Gamma Knife Radiosurgery
A one-day, less-invasive outpatient procedure that involves precisely focusing radiation beams onto the AVF, Gamma Knife radiosurgery causes the AVF to shrink over time. In many cases, the AVF will be cured 1-3 years after treatment.


A Cerebrovascular conference is  held once a week. All cerebrovascular cases are reviewed by neurosurgeons and interventional neuroradiologists to determine an optimal, individualized treatment plan. 

Physicians wishing to submit cases for review should contact the Cerebrovascular Nurse Coordinator at 314-747-8871.


Neurosurgery Providers

Interventional Neuroradiology Providers

  • DeWitte T. Cross, MD
  • Colin P. Derdeyn, MD
  • Christopher J. Moran, MD

Radiation Oncologists

  • Stephanie Perkins, MD
  • Clifford Robinson, MD
  • Joseph Simpson, MD, PhD, FACR

Critical Care Neurology Providers

  • Rajat Dhar, MD
  • Michael Diringer, MD
  • Salah G. Keyrouz, MD
  • Terrance Kummer, MD, PhD

Neuro-Rehabilitation Providers

  • Alex Carter, MD
  • Maurizio Corbetta, MD
  • Robert Fucetola, PhD
  • Thy Huskey, MD


Because of our expertise, minimally invasive techniques are often used for the treatment of AVFs.

Intraoperative angiography is routinely used to confirm effectiveness of AVF treatment at time of surgery