Dural arteriovenous fistula (DAVF) is a complex condition and several different classifications have been proposed focusing on venous drainage directions. This study was to evaluate a practical and easy-to-follow Zipfel's classification for DAVFs based on new natural history data.

From 2014 to 2018, 143 patients of DAVFs (including 134 cerebral and 9 spinal) were consecutively retrospectively reviewed. Patients' pre-treatment status(pre-mRS) were analyzed using one-way ANOVA between Borden, Cognard and Zipfel's classifications. Patients' characteristics, treatments and outcomes were also analyzed between 3 groups of Zipfel's type I, II and III.

The results of one-way ANOVA indicated that pre-mRS was significantly different between Zipfel's type and Cognard classifications (p<0.001 and p<0.001, respectively). This suggested that patients' pre-mRS was better distributed in Zipfel's classification than Cognard classification. In Zipfel's classification, male and non-sinus location were correlated with the Zipfel's type III DAVF (p<0.001). More than 3 arterial feeders and pial arterial suppliers were associated with a high grade (Zipfel's type II and III) DAVF (p=0.003). Worse symptoms were observed in Zipfel's type II and III DAVF (p=0.003) and aggressive endovascular treatment was needed (p<0.001). Transarterial treatment was usually used in Zipfel's type III DAVF and transvenous treatment was used commonly in Zipfel's type II DAVF (p<0.001).

The Zipfel's classification could evaluate the hemodynamic and clinical status of DAVFs and guide their treatment. The Zipfel's classification was informative by providing an effective assessment for the natural history of patients with simple but precise method.