Evolving Management Paradigms in Dural Arteriovenous Fistulas: From Classification to Personalized Endovascular Therapy

Dural arteriovenous fistulas (dAVFs) represent a unique subset of intracranial vascular malformations characterized by pathologic shunting between dural arteries and venous sinuses or cortical veins. Although once considered rare and uniformly high-risk, modern imaging and therapeutic innovations have revealed a spectrum of biological behavior ranging from benign to aggressive. The past decade has witnessed a paradigm shift from purely anatomic classification toward individualized, hemodynamic-based decision-making that incorporates endovascular, microsurgical, and radiosurgical techniques. This Perspective reviews the evolving management of dAVFs, emphasizing early recognition of cortical venous drainage, endovascular innovation, venous sinus reconstruction, and the emerging role of artificial intelligence and personalized medicine in risk stratification. Accordingly, we seek to delineate how a precision approach based on angioarchitecture, patterns of venous flow, and clinical phenotype has transformed the treatment of dAVFs from a purely reactive to a potentially curative discipline.