169 Stereotactic Radiosurgery for Dural Arteriovenous Fistulas Without Cortical Venous Reflux

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 243-243
Author(s):  
Daniel Tonetti ◽  
Bradley A Gross ◽  
Brian T Jankowitz ◽  
Kyle M Atcheson ◽  
Hideyuki Kano ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Low Risk ◽  
Pulsatile Tinnitus ◽  
Patient Counseling ◽  
Venous Reflux ◽  
Obliteration Rate ◽  
Arteriovenous Fistulas ◽  
Ocular Symptoms ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Reflux

Abstract INTRODUCTION The rationale for treatment of dural arteriovenous fistulas (dAVF) without cortical venous reflux is symptomatic resolution. Most studies of dural arteriovenous fistula treatment, including those for stereotactic radiosurgery, have focused on angiographic obliteration instead of clinical symptomatic outcome. METHODS The authors evaluated their institutional experience with stereotactic radiosurgery for cerebral dAVFs without cortical venous reflux from 1991 to 2016, evaluating angiographic and clinical outcomes and focusing on the course of pulsatile tinnitus and/or ocular symptoms after treatment. They subsequently pooled their results with those published in the literature. RESULTS >Pooled outcomes data from 120 patients with pulsatile tinnitus and 229 patients with ocular symptoms were analyzed. Over a mean follow-up of 2.6 years, 77% of patients presenting with pulsatile tinnitus experienced resolution and an additional 21% had improvement, with an angiographic obliteration rate of 70.9%. Among 229 patients with ocular symptoms from carotid-cavernous dAVFs, improvement or resolution of symptoms occurred in 95% of those with chemosis, 90% of those with ophthalmoplegia, and 96% of those with proptosis. The angiographic obliteration rate was 76.2%. There were eight permanent complications out of 349 total treated low-risk dAVF (2.3%). CONCLUSION Rates of clinically-significant symptomatic improvement or resolution of symptoms referable to “low risk” dAVFs are even higher than their angiographic obliteration rate, an important factor in patient counseling and when considering the optimal treatment approach for these dAVFs.

Stereotactic Radiosurgery for Dural Arteriovenous Fistulas without Cortical Venous Reflux

2017 ◽  
Vol 107 ◽  
pp. 371-375 ◽  
Author(s):  
Daniel A. Tonetti ◽  
Bradley A. Gross ◽  
Brian T. Jankowitz ◽  
Kyle M. Atcheson ◽  
Hideyuki Kano ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Venous Reflux ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Reflux

Surgical Disconnection of the Cortical Venous Reflux for High-Grade Intracranial Dural Arteriovenous Fistulas

2015 ◽  
Vol 83 (4) ◽  
pp. 652-656 ◽  
Author(s):  
Rafid Al-Mahfoudh ◽  
Ramez Kirollos ◽  
Paul Mitchell ◽  
Maggie Lee ◽  
Hans Nahser ◽  
...  
Keyword(s):  
High Grade ◽  
Venous Reflux ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Reflux

scholarly journals Reconsidering an important subclass of high-risk dural arteriovenous fistulas for stereotactic radiosurgery

2019 ◽  
Vol 130 (3) ◽  
pp. 972-976 ◽  
Author(s):  
Daniel A. Tonetti ◽  
Bradley A. Gross ◽  
Brian T. Jankowitz ◽  
Hideyuki Kano ◽  
Edward A. Monaco ◽  
...  
Keyword(s):  
High Risk ◽  
Stereotactic Radiosurgery ◽  
Significant Risk ◽  
Venous Drainage ◽  
Significant Risk Factor ◽  
Low Risk ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Institutional Experience ◽  
Cortical Venous Drainage

OBJECTIVEAggressive dural arteriovenous fistulas (dAVFs) with cortical venous drainage (CVD) are known for their relatively high risk of recurrent neurological events or hemorrhage. However, recent natural history literature has indicated that nonaggressive dAVFs with CVD have a significantly lower prospective risk of hemorrhage. These nonaggressive dAVFs are typically diagnosed because of symptomatic headache, pulsatile tinnitus, or ocular symptoms, as in low-risk dAVFs. Therefore, the viability of stereotactic radiosurgery (SRS) as a treatment for this lesion subclass should be investigated.METHODSThe authors evaluated their institutional experience with SRS for dAVFs with CVD for the period from 1991 to 2016, assessing angiographic outcomes and posttreatment hemorrhage rates. They subsequently pooled their results with those published in the literature and stratified the results based on the mode of clinical presentation.RESULTSIn an institutional cohort of 42 dAVFs with CVD treated using SRS, there were no complications or hemorrhages after treatment in 19 patients with nonaggressive dAVFs, but there was 1 radiation-induced complication and 1 hemorrhage among the 23 patients with aggressive dAVFs. In pooling these cases with 155 additional cases from the literature, the authors found that the hemorrhage rate after SRS was significantly lower among the patients with nonaggressive dAVFs (0% vs 6.8%, p = 0.003). Similarly, the number of radiation-related complications was 0/124 in nonaggressive dAVF cases versus 6/73 in aggressive dAVF cases (p = 0.001). The annual rate of hemorrhage after SRS for aggressive fistulas was 3.0% over 164.5 patient-years, whereas none of the nonaggressive fistulas bled after radiosurgery over 279.4 patient-years of follow-up despite the presence of CVD.CONCLUSIONSCortical venous drainage is thought to be a significant risk factor in all dAVFs. In the institutional experience described here, SRS proved to be a low-risk strategy associated with a very low risk of subsequent hemorrhage or radiation-related complications in nonaggressive dAVFs with CVD.

scholarly journals Clinical Course of Cranial Dural Arteriovenous Fistulas With Long-Term Persistent Cortical Venous Reflux

Stroke ◽  
2002 ◽  
Vol 33 (5) ◽  
pp. 1233-1236 ◽  
Author(s):  
J. Marc C. van Dijk ◽  
Karel G. terBrugge ◽  
Robert A. Willinsky ◽  
M. Christopher Wallace
Keyword(s):  
Clinical Course ◽  
Venous Reflux ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Reflux

Stereotactic Radiosurgery With or Without Embolization for Intracranial Dural Arteriovenous Fistulas

Neurosurgery ◽  
2010 ◽  
Vol 67 (5) ◽  
pp. 1276-1285 ◽  
Author(s):  
Huai-che Yang ◽  
Hideyuki Kano ◽  
Douglas Kondziolka ◽  
Ajay Niranjan ◽  
John C Flickinger ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Treatment Options ◽  
Target Volume ◽  
Symptom Improvement ◽  
Effective Treatment Option ◽  
Obliteration Rate ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Carotid Cavernous Fistulas

Abstract BACKGROUND: Treatment options for dural arteriovenous fistulas (DAVFs) have expanded with the application of stereotactic radiosurgery (SRS). OBJECTIVE: To assess the role of SRS with or without embolization, we reviewed our entire DAVF experience. METHODS: Between 1991 and 2006, 40 patients with 44 DAVFs underwent Gamma knife SRS. Twenty-eight patients had upfront SRS before or after embolization and 12 patients underwent delayed SRS for recurrent or residual DAVFs after initial embolization. The median patient age was 60 years (range, 29-90). DAVFs were diagnosed in 7 patients after they sustained an intracranial hemorrhage. The median SRS target volume was 2.0 mL (range, 0.2-8.2 mL) and the median marginal dose was 21.0 Gy (range, 15-25 Gy). RESULTS: At a median follow-up of 45 months (range, 23-116 mo), a total of 28 patients (harboring 32 DAVFs) had obliteration confirmed by imaging. We found a 83% obliteration rate in patients who had upfront SRS with embolization and a 67% obliteration rate in patients who only had SRS. One patient died of an intracerebral hemorrhage 2 months after SRS. Cavernous carotid fistulas were associated with higher rates of occlusion (P = .012) and symptom improvement (P = .010) than were transverse-sigmoid sinus-related fistulas. CONCLUSION: When upfront SRS is possible in conjunction with embolization, successful DAVF obliteration is possible in most patients, especially those with carotid cavernous fistulas. SRS should target the entire fistula regardless of whether it precedes or follows embolization. In selected patients with a small-volume, low-risk DAVF, SRS alone is an effective treatment option in most patients.

scholarly journals Lateral Sinus Dural Arteriovenous Fistulas: Sinovenous Outflow Restriction Outweighs Cortical Venous Reflux as a Parameter Associated with Hemorrhage

Radiology ◽  
2017 ◽  
Vol 285 (2) ◽  
pp. 528-535 ◽  
Author(s):  
Yong-Sin Hu ◽  
Chung-Jung Lin ◽  
Hsiu-Mei Wu ◽  
Wan-Yuo Guo ◽  
Chao-Bao Luo ◽  
...  
Keyword(s):  
Lateral Sinus ◽  
Venous Reflux ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Reflux

scholarly journals Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

2015 ◽  
Vol 122 (2) ◽  
pp. 353-362 ◽  
Author(s):  
Ching-Jen Chen ◽  
Cheng-Chia Lee ◽  
Dale Ding ◽  
Robert M. Starke ◽  
Srinivas Chivukula ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Venous Drainage ◽  
Classification Systems ◽  
Complication Rates ◽  
Obliteration Rate ◽  
Arteriovenous Fistulas ◽  
Significant Difference ◽  
Dural Arteriovenous Fistulas ◽  
Complete Obliteration ◽  
Cortical Venous Drainage

OBJECT The goal of this study was to evaluate the obliteration rate of intracranial dural arteriovenous fistulas (DAVFs) in patients treated with stereotactic radiosurgery (SRS), and to compare obliteration rates between cavernous sinus (CS) and noncavernous sinus (NCS) DAVFs, and between DAVFs with and without cortical venous drainage (CVD). METHODS A systematic literature review was performed using PubMed. The CS DAVFs and the NCS DAVFs were categorized using the Barrow and Borden classification systems, respectively. The DAVFs were also categorized by location and by the presence of CVD. Statistical analyses of pooled data were conducted to assess complete obliteration rates in CS and NCS DAVFs, and in DAVFs with and without CVD. RESULTS Nineteen studies were included, comprising 729 patients harboring 743 DAVFs treated with SRS. The mean obliteration rate was 63% (95% CI 52.4%–73.6%). Complete obliteration for CS and NCS DAVFs was achieved in 73% and 58% of patients, respectively. No significant difference in obliteration rates between CS and NCS DAVFs was found (OR 1.72, 95% CI 0.66–4.46; p = 0.27). Complete obliteration in DAVFs with and without CVD was observed in 56% and 75% of patients, respectively. A significantly higher obliteration rate was observed in DAVFs without CVD compared with DAVFs with CVD (OR 2.37, 95% CI 1.07–5.28; p = 0.03). CONCLUSIONS Treatment with SRS offers favorable rates of DAVF obliteration with low complication rates. Patients harboring DAVFs that are refractory or not amenable to endovascular or surgical therapy may be safely and effectively treated using SRS.

Stereotactic radiosurgery for cerebral dural arteriovenous fistulas

2012 ◽  
Vol 32 (5) ◽  
pp. E18 ◽  
Author(s):  
Bradley A. Gross ◽  
Alexander E. Ropper ◽  
A. John Popp ◽  
Rose Du
Keyword(s):  
Stereotactic Radiosurgery ◽  
Venous Drainage ◽  
Review Of The Literature ◽  
Obliteration Rate ◽  
Arteriovenous Fistulas ◽  
The Past ◽  
Relative Paucity ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Drainage

Object Given the feasibility of curative surgical and endovascular therapy for cerebral dural arteriovenous fistulas (DAVFs), there is a relative paucity of radiosurgical series for these lesions as compared with their arteriovenous malformation counterparts. Methods The authors reviewed records of 56 patients with 70 cerebral DAVFs treated at their institution over the past 6 years. Ten DAVFs (14%) in 9 patients were treated with stereotactic radiosurgery (SRS), with follow-up obtained for 8 patients with 9 DAVFs. They combined their results with those obtained from a comprehensive review of the literature, focusing on obliteration rates, post-SRS hemorrhage rates, and other complications. Results In the authors' group of 9 DAVFs, angiographic obliteration was seen in 8 cases (89%), and no post-SRS hemorrhage or complications were observed after a mean follow-up of 2.9 years. Combining the results in these cases with data obtained from their review of the literature, they found 558 DAVFs treated with SRS across 14 series. The overall obliteration rate was 71%; transient worsening occurred in 9.1% of patients, permanent worsening in 2.4% (including 1 death, 0.2% of cases), and post-SRS hemorrhage occurred in 1.6% of cases (4.8% of those with cortical venous drainage [CVD]). The obliteration rate for cavernous DAVFs was 84%, whereas the rates for transversesigmoid and for tentorial DAVFs were 58% and 59%, respectively (adjusted p values, pcav,TS = 1.98 × 10−4, pcav,tent = 0.032). Obliteration rates were greater for DAVFs without CVD (80%, compared with 60% for those with CVD, p = 7.59 × 10−4). Both transient worsening and permanent worsening were less common in patients without CVD than in those with CVD (3.4% vs 7.3% for transient worsening and 0.9% vs 2.4% for permanent worsening). Conclusions Stereotactic radiosurgery with or without adjunctive embolization is an effective therapy for DAVFs that are not amenable to surgical or endovascular monotherapy. It is best suited for lesions without CVD and for cavernous DAVFs.

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