Observation Versus Intervention for Low-Grade Intracranial Dural Arteriovenous Fistulas

Abstract BACKGROUND Low-grade intracranial dural arteriovenous fistulas (dAVF) have a benign natural history in the majority of cases. The benefit from treatment of these lesions is controversial. OBJECTIVE To compare the outcomes of observation versus intervention for low-grade dAVFs. METHODS We retrospectively reviewed dAVF patients from institutions participating in the CONsortium for Dural arteriovenous fistula Outcomes Research (CONDOR). Patients with low-grade (Borden type I) dAVFs were included and categorized into intervention or observation cohorts. The intervention and observation cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was modified Rankin Scale (mRS) at final follow-up. Secondary outcomes were excellent (mRS 0-1) and good (mRS 0-2) outcomes, symptomatic improvement, mortality, and obliteration at final follow-up. RESULTS The intervention and observation cohorts comprised 230 and 125 patients, respectively. We found no differences in primary or secondary outcomes between the 2 unmatched cohorts at last follow-up (mean duration 36 mo), except obliteration rate was higher in the intervention cohort (78.5% vs 24.1%, P < .001). The matched intervention and observation cohorts each comprised 78 patients. We also found no differences in primary or secondary outcomes between the matched cohorts except obliteration was also more likely in the matched intervention cohort (P < .001). Procedural complication rates in the unmatched and matched intervention cohorts were 15.4% and 19.2%, respectively. CONCLUSION Intervention for low-grade intracranial dAVFs achieves superior obliteration rates compared to conservative management, but it fails to improve neurological or functional outcomes. Our findings do not support the routine treatment of low-grade dAVFs.

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Abstract 125: Observation versus Treatment for Low-Grade Intracranial Dural Arteriovenous Fistulas: A Multicenter Matched Cohort Study

Stroke ◽

10.1161/str.51.suppl_1.125 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ching-jen Chen ◽

Thomas Buell ◽

Ridhima Guniganti ◽

Isaac Abecassis ◽

Giuseppe Lanzino ◽

...

Keyword(s):

Conservative Management ◽

Functional Disability ◽

Symptomatic Improvement ◽

Low Grade ◽

Matched Cohort ◽

Routine Treatment ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Secondary Outcomes

Background and Purpose: Given the benign natural history of intracranial low-grade dural arteriovenous fistulas (dAVFs), their routine treatment remains controversial. The aim of this study is to compare the outcomes of low-grade dAVF treatment to conservative management. Methods: We performed a retrospective review of dAVF patients derived from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with low-grade (Borden I) dAVFs were included and categorized into treatment and observation cohorts. Primary outcome was defined as modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were rates of excellent (mRS 0-1) and good (mRS 0-2) functional outcomes, symptomatic improvement, mortality, and obliteration at final follow-up. Results: The treatment and observation cohorts comprised 230 and 112 patients, respectively. At last follow up, no difference in primary or secondary outcomes was observed between the two cohorts, with the exception of obliteration, which was higher in the treatment cohort (79.3% vs. 28.2%, p<0.001; Table 1). The two cohorts were then matched in a 1:1 ratio, resulting in 64 patients in each matched cohort. No difference in primary or secondary outcomes was observed between the matched cohorts, with the exception of obliteration, which was higher in the matched treatment cohort (75.4% vs. 28.6%, p<0.001; Table 2). Subgroup analysis of symptomatic patients demonstrated higher obliteration rate in the treatment cohort, but no difference in primary or other secondary outcomes were found. Conclusions: Low-grade dAVF treatment was not associated with increased functional disability compared to conservative management. Although higher obliteration rates were achieved in the treatment cohort, rates of symptomatic improvement were similar between the two cohorts. This study did not provide evidence to support the routine treatment of low-grade dAVFs.

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Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18

Journal of Neurosurgery ◽

10.3171/jns.2008.109.12.1083 ◽

2008 ◽

Vol 109 (6) ◽

pp. 1083-1090 ◽

Cited By ~ 42

Author(s):

Xianli Lv ◽

Chuhan Jiang ◽

Youxiang Li ◽

Zhongxue Wu

Keyword(s):

Transarterial Embolization ◽

Clinical Status ◽

Complication Rates ◽

Trigeminocardiac Reflex ◽

Arteriovenous Fistulas ◽

Liquid Embolic ◽

Definitive Therapy ◽

Dural Arteriovenous Fistulas ◽

Scale Scores

Object Use of the Onyx liquid embolic system has become an option for treating dural arteriovenous fistulas (DAVFs) because of its advantageous nonadhesive and cohesive properties. However, the complication rates associated with the use of this system have not been reported. The authors present their initial experience of the risks related to transarterial embolization using this system. Methods Between February 2005 and February 2007, 31 patients with DAVFs were treated at Beijing Tiantan Hospital. Transarterial embolization using Onyx-18 was performed as a preoperative adjunct or as definitive therapy. The demographic characteristics, angiographic features, clinical presentation, treatment, and outcome of the patients were reviewed. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores. Results In 19 patients (61.3%) there was complete angiographic evidence of elimination of the shunts and resolution of the symptoms. The remaining 12 patients were treated successfully but did not attain complete embolization and had residual shunting. Adverse events occurred in 5 of 31 patients, with 3 DAVFs located at the tentorium, 1 at the inferior petrosal sinus, and 1 at the cavernous sinus. Complications included trigeminocardiac reflex in 2 patients (6.5%), hemifacial hypesthesia in 3 patients (9.7%), hemifacial palsy in 2 patients (6.5%), jaw pain in 1 patient (3.2%), posterior fossa infarction in 1 patient (3.2%), and microcatheter gluing in 1 patient (3.2%). At the last follow-up examination, all patients had returned to an independent clinical status. Conclusions Although a complete resolution of symptoms can be achieved with transarterial embolization using the Onyx liquid embolic system, the potential for serious complications exists with this procedure, necessitating the participation of a skilled neurointerventionalist.

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Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse—sigmoid sinus

Journal of Neurosurgery ◽

10.3171/jns.2002.96.5.0823 ◽

2002 ◽

Vol 96 (5) ◽

pp. 823-829 ◽

Cited By ~ 59

Author(s):

David Hung-chi Pan ◽

Wen-yuh Chung ◽

Wan-yuo Guo ◽

Hsiu-mei Wu ◽

Kang-du Liu ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Neurological Complication ◽

Endovascular Embolization ◽

Sigmoid Sinus ◽

Type I ◽

Content Type ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Fine Print

Object. The aim of this study was to assess the efficacy and safety of radiosurgery for the treatment of dural arteriovenous fistulas (DAVFs) located in the region of the transverse—sigmoid sinus. Methods. A series of 20 patients with DAVFs located in the transverse—sigmoid sinus, who were treated with gamma knife surgery between June 1995 and June 2000, was evaluated. According to the Cognard classification, the DAVF was Type I in four patients, Type IIa in seven, Type IIb in two, and combined Type IIa+b in seven. Nine patients had previously been treated with surgery and/or embolization, whereas 11 patients underwent radiosurgery alone. Radiosurgery was performed using multiple-isocenter irradiation of the delineated DAVF nidus. The target volume ranged from 1.7 to 40.7 cm3. The margin dose delivered to the nidus ranged from 16.5 to 19 Gy at a 50 to 70% isodose level. Nineteen patients were available for follow-up review, the duration of which ranged from 6 to 58 months (median 19 months). Of the 19 patients, 14 (74%) were cured of their symptoms. At follow up, magnetic resonance imaging and/or angiography demonstrated complete obliteration of the DAVF in 11 patients (58%), subtotal obliteration (95% reduction of the nidus) in three (16%), and partial obliteration in another five (26%). There was no neurological complication related to the treatment. One patient experienced a recurrence of the DAVF 18 months after angiographic confirmation of total obliteration, and underwent a second course of radiosurgery. Conclusions. Stereotactic radiosurgery provides a safe and effective option for the treatment of DAVFs involving the transverse and sigmoid sinuses. For some aggressive DAVFs with extensive retrograde cortical venous drainage, however, a combination of endovascular embolization and surgery may be necessary.

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Borden-Shucart Type I dural arteriovenous fistulas: clinical course including risk of conversion to higher-grade fistulas

Journal of Neurosurgery ◽

10.3171/2012.5.jns111257 ◽

2012 ◽

Vol 117 (3) ◽

pp. 539-545 ◽

Cited By ~ 23

Author(s):

Manish N. Shah ◽

James A. Botros ◽

Thomas K. Pilgram ◽

Christopher J. Moran ◽

DeWitte T. Cross ◽

...

Keyword(s):

Intracranial Hemorrhage ◽

Clinical Course ◽

Retrospective Chart Review ◽

Annual Rate ◽

Neurological Deficits ◽

Type I ◽

Arteriovenous Fistulas ◽

Presenting Symptoms ◽

Dural Arteriovenous Fistulas

Object The goal of this study was to determine the clinical course of Borden-Shucart Type I cranial dural arteriovenous fistulas (DAVFs) and to calculate the annual rate of conversion of these lesions to more aggressive fistulas that have cortical venous drainage (CVD). Methods A retrospective chart review was conducted of all patients harboring DAVFs who were seen at the authors' institution between 1997 and 2009. Twenty-three patients with Type I DAVFs who had available clinical follow-up were identified. Angiographic and clinical data from these patients were reviewed. Neurological outcome and status of presenting symptoms were assessed during long-term follow-up. Results Of the 23 patients, 13 underwent endovascular treatment for intolerable tinnitus or ophthalmological symptoms, and 10 did not undergo treatment. Three untreated patients died of unrelated causes. In those who were treated, complete DAVF obliteration was achieved in 4 patients, and palliative reduction in DAVF flow was achieved in 9 patients. Of the 19 patients without radiographic cure, no patient developed intracranial hemorrhage or nonhemorrhagic neurological deficits (NHNDs), and no patient died of DAVF-related causes over a mean follow-up of 5.6 years. One patient experienced a spontaneous, asymptomatic obliteration of a partially treated DAVF in late follow-up, and 2 patients experienced a symptomatic conversion of their DAVF to a higher-grade fistula with CVD in late follow-up. The annual rate of conversion to a higher-grade DAVF based on Kaplan-Meier cumulative event-free survival analysis was 1.0%. The annual rate of intracranial hemorrhage, NHND, and DAVF-related death was 0.0%. Conclusions A small number of Type I DAVFs will convert to more aggressive DAVFs with CVD over time. This conversion to a higher-grade DAVF is typically heralded by a change in patient symptoms. Follow-up vascular imaging is important, particularly in the setting of recurrent or new symptoms.

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Use of a self-expanding stent with balloon angioplasty in the treatment of dural arteriovenous fistulas involving the transverse and/or sigmoid sinus: functional and neuroimaging-based outcome in 10 patients

Journal of Neurosurgery ◽

10.3171/jns.2006.104.2.254 ◽

2006 ◽

Vol 104 (2) ◽

pp. 254-263 ◽

Cited By ~ 37

Author(s):

Olivier Levrier ◽

Philippe Métellus ◽

Stephane Fuentes ◽

Luis Manera ◽

Henry Dufour ◽

...

Keyword(s):

Clinical Improvement ◽

Balloon Angioplasty ◽

Stent Placement ◽

Sigmoid Sinus ◽

Stent Insertion ◽

Type I ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

The Mean

Object The goal of this study was to evaluate the clinical and angiography results in 10 patients with transverse–sigmoid dural arteriovenous fistulas (DAVFs) treated using sinus angioplasty and dural sinus stent insertion. Methods Between 2001 and 2003, 10 consecutive patients (six men and four women, age range 54–79 years) who had presented with transverse and/or sigmoid sinus DAVFs with or without sinus thrombosis underwent self-expanding stent placement and balloon angioplasty. Eight fistulas involved the transverse sinus, three the sigmoid sinus, and one the torcular and occipital sinuses. According to the Djindjian-Merland grading system, there were two Type I, five Type IIa, one Type IIb, and two Type IV DAVFs. The mean clinical follow-up period was 21.1 months. At the last follow-up examination, seven patients were asymptomatic and three were dramatically improved. The mean angiography follow-up period was 7.5 months for the available population: four patients had complete DAVF occlusion, four had significant flow reduction, and two who experienced clinical improvement refused conventional angiography control studies. Delayed computerized tomography angiography scans were obtained to evaluate stent permeability in nine of the 10 patients. Stent permeability was demonstrated in eight of the nine patients with available control studies at a mean follow up of 20.8 months. There were two transient neurological deficits but no severe and permanent complications. Conclusions In this series, sinus stent insertion resulted in a cure or significant clinical improvement in all patients harboring a DAVF, with no severe or permanent complication. Stent placement for transverse and/or sigmoid sinus DAVFs is a promising technique whose viability should be confirmed in larger series with longer follow-up periods.

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Transarterial embolization of dural arteriovenous fistulas of the lateral sinuses with stent-assisted sinus protection

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018176 ◽

2021 ◽

pp. neurintsurg-2021-018176

Author(s):

Alexis Guédon ◽

Mahmoud Elhorany ◽

Marc-Antoine Labeyrie ◽

Vittorio Civelli ◽

Jean-Pierre Saint-Maurice ◽

...

Keyword(s):

Transarterial Embolization ◽

Type I ◽

Lateral Sinus ◽

Arteriovenous Fistulas ◽

Closed Cell ◽

Dural Arteriovenous Fistulas ◽

Superior Petrosal Sinus ◽

Procedural Complications ◽

A New Technique

BackgroundThe balloon-assisted sinus protection technique has been described as a sinus-preserving technique during transarterial embolization (TAE) of dural arteriovenous fistulas (DAVFs). However, some serious complications of this technique have been documented.ObjectiveTo describe our preliminary experience with a new technique called stent-assisted sinus protection (SSP).MethodsWe performed a retrospective analysis of seven consecutive patients with type I or IIa DAVFs of the lateral sinus treated by TAE with a closed-cell stent temporarily deployed in the sinus.ResultsOf the seven patients, four had type I DAVF, and three had type IIa DAVF. The patency of all involved sinuses and their tributaries (including the inferior anastomotic vein and the superior petrosal sinus) was preserved. At the end of the procedure, all stents were successfully retrieved with embolic particles trapped in their meshes. No procedural complications were noted. Clinical follow-up was satisfactory, with complete resolution or significant reduction of pulsatile tinnitus.ConclusionsSSP appears to be feasible and probably safe. However, larger studies are needed to confirm these preliminary results.

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Endovascular therapy of low- and intermediate-grade intracranial lateral dural arteriovenous fistulas: a detailed analysis of primary success rates, complication rates, and long-term follow-up of different technical approaches

Journal of Neurosurgery ◽

10.3171/2016.2.jns152081 ◽

2017 ◽

Vol 126 (2) ◽

pp. 360-367 ◽

Cited By ~ 10

Author(s):

Lorenz Ertl ◽

Hartmut Brückmann ◽

Mathias Kunz ◽

Alexander Crispin ◽

Gunther Fesl

Keyword(s):

Complication Rate ◽

Complication Rates ◽

Success Rates ◽

Intermediate Grade ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Primary Success ◽

Long Term Follow Up

OBJECTIVE Sinus-preserving (SP) embolization techniques augment endovascular treatment options for intracranial lateral dural arteriovenous fistulas (DAVFs). The authors aimed to perform a retrospective comparison of their primary success rates, complication rates, and long-term follow-up with those of sinus-occluding (SO) treatment variants in the collective of low- and intermediate-grade lateral DAVFs (Cognard Types I–IIb). METHODS Clinical symptoms, complication rates, and Cognard grading prior to and after endovascular DAVF treatment using different technical approaches was retrospectively analyzed in 36 patients with lateral DAVF Cognard Types I–IIb. The long-term success rate was determined by a standardized questionnaire. RESULTS The SO approaches offered a higher rate of definitive fistula occlusion (93% SO vs 71% SP) but were accompanied by a significantly higher complication rate (33% or 20% SO vs 0% SP). The patients interviewed reported very high satisfaction with their health in long-term follow-up in both groups. CONCLUSIONS A higher rate of definitive fistula occlusion in the SO group was attained at the price of a significantly higher complication rate. The SP approaches offered a good primary success rate in combination with a very low complication rate. Despite some limitations of the data (e.g., a small sample size) the authors thus recommend an SP variant as the primary therapeutic option for the endovascular treatment of low- and intermediate-grade DAVFs. The SO approaches should be restricted to cases in which SP treatment does not achieve a downgrading to no worse than Cognard Type IIa.

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Intraarterial and Intravenous Treatment of Transverse/Sigmoid Sinus Dural Arteriovenous Fistulas

Interventional Neuroradiology ◽

10.1177/159101990901500306 ◽

2009 ◽

Vol 15 (3) ◽

pp. 291-300 ◽

Cited By ~ 5

Author(s):

X. Lv ◽

C. Jiang ◽

Y. Li ◽

X. Yang ◽

Z. Wu

Keyword(s):

Treatment Strategy ◽

Arterial Embolization ◽

Sigmoid Sinus ◽

Embolic Agent ◽

Type I ◽

Arteriovenous Fistulas ◽

Common Location ◽

Additional Surgery ◽

Dural Arteriovenous Fistulas

Transverse/sigmoid sinus (TS) is the most common location for cerebral dural arteriovenous fistulas (DAVFs). Most of them are cured by venous embolization or a combination of arterial embolization and surgery/radiosurgery. Our goal was to reconsider the endovascular treatment strategy of TSDAVFs according to the new possibilities of arterial embolization using Onyx-18. Nineteen patients with TSDAVFs were included in a prospective study between 2004 and 2007. Three of them had type I, four had type IIa, six had type IIa+b, three had type III, and three had type IV fistulas. Three presented with subarachnoid hemorrhage. The approach routes, angiographic results, complications, and clinical outcome were assessed. The mean clinical follow-up period was 32.5 months. In one patient, the DAVF had been obliterated spontaneously at ten month follow-up. Complete angiographic cure was obtained in nine cases with one case of progressive thrombosis. Of these ten cures were achieved after a single procedure in seven out of ten patients who had not been embolized previously. Three patients were cured with sinus packing with prior arterial embolization. Among these 19 patients, 15 underwent follow-up angiography which confirmed the complete cure. Partial occlusion was obtained in nine patients, one was cured after additional surgery, and one underwent radiosurgery. Hallucination occurred in one completely cured patient on day one. Based on this experience, we believe that intraarterial Onyx may be the primary treatment of choice for patients with TSDAVFs. The applicability of this new embolic agent indicates the need for reconsideration of the treatment strategy for such fistulas.

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Dural arteriovenous fistulas without cortical venous drainage: presentation, treatment, and outcomes

Journal of Neurosurgery ◽

10.3171/2021.1.jns202825 ◽

2021 ◽

pp. 1-9

Author(s):

Edgar A. Samaniego ◽

Jorge A. Roa ◽

Minako Hayakawa ◽

Ching-Jen Chen ◽

Jason P. Sheehan ◽

...

Keyword(s):

Open Surgery ◽

Spontaneous Regression ◽

Venous Drainage ◽

Current Evidence ◽

Type I ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

The Mean ◽

Cortical Venous Drainage

OBJECTIVE Current evidence suggests that intracranial dural arteriovenous fistulas (dAVFs) without cortical venous drainage (CVD) have a benign clinical course. However, no large study has evaluated the safety and efficacy of current treatments and their impact over the natural history of dAVFs without CVD. METHODS The authors conducted an analysis of the retrospectively collected multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database. Patient demographics and presenting symptoms, angiographic features of the dAVFs, and treatment outcomes of patients with Borden type I dAVFs were reviewed. Clinical and radiological follow-up information was assessed to determine rates of new intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND), worsening of venous hyperdynamic symptoms (VHSs), angiographic recurrence, and progression or spontaneous regression of dAVFs over time. RESULTS A total of 342 patients/Borden type I dAVFs were identified. The mean patient age was 58.1 ± 15.6 years, and 62% were women. The mean follow-up time was 37.7 ± 54.3 months. Of 230 (67.3%) treated dAVFs, 178 (77%) underwent mainly endovascular embolization, 11 (4.7%) radiosurgery alone, and 4 (1.7%) open surgery as the primary modality. After the first embolization, most dAVFs (47.2%) achieved only partial reduction in early venous filling. Multiple complementary interventions increased complete obliteration rates from 37.9% after first embolization to 46.7% after two or more embolizations, and 55.2% after combined radiosurgery and open surgery. Immediate postprocedural complications occurred in 35 dAVFs (15.2%) and 6 (2.6%) with permanent sequelae. Of 127 completely obliterated dAVFs by any therapeutic modality, 2 (1.6%) showed angiographic recurrence/recanalization at a mean of 34.2 months after treatment. Progression to Borden-Shucart type II or III was documented in 2.2% of patients and subsequent development of a new dAVF in 1.6%. Partial spontaneous regression was found in 22 (21.4%) of 103 nontreated dAVFs. Multivariate Cox regression analysis demonstrated that older age, NHND, or severe venous-hyperdynamic symptoms at presentation and infratentorial location were associated with worse prognosis. Kaplan-Meier curves showed no significant difference for stable/improved symptoms survival probability in treated versus nontreated dAVFs. However, estimated survival times showed better trends for treated dAVFs compared with nontreated dAVFs (288.1 months vs 151.1 months, log-rank p = 0.28). This difference was statistically significant for treated dAVFs with 100% occlusion (394 months, log-rank p < 0.001). CONCLUSIONS Current therapeutic modalities for management of dAVFs without CVD may provide better symptom control when complete angiographic occlusion is achieved.

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Gamma Knife surgery for clival epidural-osseous dural arteriovenous fistulas

Journal of Neurosurgery ◽

10.3171/2017.1.jns161346 ◽

2018 ◽

Vol 128 (5) ◽

pp. 1364-1371 ◽

Cited By ~ 3

Author(s):

Cheng-Chia Lee ◽

Ching-Jen Chen ◽

Shao-Ching Chen ◽

Huai-Che Yang ◽

Chung Jung Lin ◽

...

Keyword(s):

Gamma Knife ◽

Case Series ◽

Latency Period ◽

Venous Drainage ◽

Symptomatic Improvement ◽

Gamma Knife Surgery ◽

Type I ◽

Arteriovenous Fistulas ◽

Complete Obliteration

OBJECTIVEClival epidural-osseous dural arteriovenous fistula (DAVF) is often associated with a large nidus, multiple arterial feeders, and complex venous drainage. In this study the authors report the outcomes of clival epidural-osseous DAVFs treated using Gamma Knife surgery (GKS).METHODSThirteen patients with 13 clival epidural-osseous DAVFs were treated with GKS at the authors’ institution between 1993 and 2015. Patient age at the time of GKS ranged from 38 to 76 years (median 55 years). Eight DAVFs were classified as Cognard Type I, 4 as Type IIa, and 1 as Type IIa+b. The median treatment volume was 17.6 cm3 (range 6.2–40.3 cm3). The median prescribed margin dose was 16.5 Gy (range 15–18 Gy). Clinical and radiological follow-ups were performed at 6-month intervals. Patient outcomes after GKS were categorized as 1) complete improvement, 2) partial improvement, 3) stationary, and 4) progression.RESULTSAll 13 patients demonstrated symptomatic improvement, and on catheter angiography 12 of the 13 patients had complete obliteration and 1 patient had partial obliteration. The median follow-up period was 26 months (range 14–186 months). The median latency period from GKS to obliteration was 21 months (range 8–186 months). There was no intracranial hemorrhage during the follow-up period, and no deaths occurred. Two adverse events were observed following treatment, and 2 patients required repeat GKS treatment with eventual complete obliteration.CONCLUSIONSGamma Knife surgery offers a safe and effective primary or adjuvant treatment modality for complex clival epidural-osseous DAVFs. All patients in this case series demonstrated symptomatic improvement, and almost all patients attained complete obliteration.

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