Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

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.

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Stereotactic radiosurgery for cerebral dural arteriovenous fistulas

Neurosurgical FOCUS ◽

10.3171/2012.1.focus11354 ◽

2012 ◽

Vol 32 (5) ◽

pp. E18 ◽

Cited By ~ 14

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

Journal of Neurosurgery ◽

10.3171/2017.10.jns171802 ◽

2019 ◽

Vol 130 (3) ◽

pp. 972-976 ◽

Cited By ~ 2

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.

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Dural arteriovenous fistulas at the craniocervical junction: a systematic review

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011775 ◽

2015 ◽

Vol 8 (6) ◽

pp. 648-653 ◽

Cited By ~ 23

Author(s):

Jingjing Zhao ◽

Feng Xu ◽

Jinma Ren ◽

Sunil Manjila ◽

Nicholas C Bambakidis

Keyword(s):

English Language ◽

Venous Drainage ◽

Craniocervical Junction ◽

Female Ratio ◽

Arteriovenous Fistulas ◽

Increased Risk ◽

Significant Difference ◽

Dural Arteriovenous Fistulas ◽

Complete Obliteration ◽

Feasible Alternative

BackgroundDural arteriovenous fistulas (DAVFs) at the craniocervical junction are uncommon but clinically important abnormalities.ObjectiveTo investigate the clinical characteristics of patients with DAVFs at the craniocervical junction and assess angiographic features associated with bleeding at presentation.MethodsWe systematically reviewed the literature and searched PubMed and EMBASE for all relevant English language articles published between 1980 and 2014. The clinical presentation, angiographic characteristics, and treatment were assessed. The clinical differences between a subarachnoid hemorrhage (SAH) group and a non-SAH group were statistically examined.ResultsFifty-six patients were identified after a review of the literature (mean age 55.6 years; male to female ratio=3:1). Twenty-one patients (37.5%) presented with hemorrhage including SAH and posterior fossa hemorrhage. There was no significant difference in patient age, sex, or location of the DAVF between the SAH group and the non-SAH group. Intracranial venous drainage was significantly associated with SAH (p<0.001). The presence of a varix was significantly associated with SAH (p=0.001). Open surgery had a significantly higher efficacy of initial complete obliteration than embolization (100% vs 71.4%, p<0.01).ConclusionsDAVFs at the craniocervical junction are rare lesions, which often present with hemorrhage. Intracranial venous drainage and a venous varix are associated with increased risk of SAH. Surgical interruption of the feeding arteries or draining veins is an effective and reliable method for treating DAVFs at the craniocervical junction. Embolization is a feasible alternative to surgery in the treatment of selective DAVFs.

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Treatment of cranial dural arteriovenous fistulas with exclusive cortical venous drainage: A single-center cohort of 35 patients

Interventional Neuroradiology ◽

10.1177/1591019917728399 ◽

2017 ◽

Vol 23 (6) ◽

pp. 661-665 ◽

Cited By ~ 5

Author(s):

HG Kortman ◽

G Bloemsma ◽

I Boukrab ◽

JP Peluso ◽

M Sluzewski ◽

...

Keyword(s):

Incidental Finding ◽

Multimodality Treatment ◽

Venous Drainage ◽

Primary Treatment ◽

Neurological Deficits ◽

Blurred Vision ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Complete Obliteration ◽

Cortical Venous Drainage

Background and purpose Dural arteriovenous fistulas (DAVFs) with cortical venous drainage often present with hemorrhage or neurological deficits and prompt treatment is indicated. Disconnection of the draining vein is considered curative. We present the multimodality treatment results of 35 patients with cranial DAVFs with exclusive cortical venous drainage. Materials and methods Between January 2010 and January 2017, 35 consecutive patients with cranial dural fistulas with exclusive cortical venous drainage were treated. There were 27 men and eight women, mean age 68 years (range 45–87). Clinical presentation was hemorrhage in 23 (66%), pulsatile bruit in two (6%), seizures in one (3%) and blurred vision in one (3%). In eight patients (22%), the DAVF was an incidental finding. Location of the DAVFs was convexity in 25 (71%), posterior fossa in eight (23%) and tentorium in two (6%). Results Surgery was performed in four patients with anterior cranial fossa fistulas and in one patient with a tentorial dural fistula. In 30 patients, embolization with Onyx via the arterial route was the primary treatment with complete obliteration in one session in 25 patients. Additional surgical or endovascular sessions were necessary in five patients after incomplete embolization and in one patient after incomplete surgery. Obliteration was confirmed with angiography after three months. There were no procedural complications. Conclusions Patients with dural fistulas with cortical venous drainage were cured with a strategy of arterial endovascular treatment with Onyx and surgery. These techniques were either primarily successful or complementary. There were no complications of treatment.

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Endovascular management of complex superior sagittal sinus dural arteriovenous fistula

Neurosurgical FOCUS ◽

10.3171/2019.2.focusvid.18687 ◽

2019 ◽

Vol 46 (Suppl_2) ◽

pp. V11

Author(s):

André Beer-Furlan ◽

Krishna C. Joshi ◽

Hormuzdiyar H. Dasenbrock ◽

Michael Chen

Keyword(s):

Dural Arteriovenous Fistula ◽

Superior Sagittal Sinus ◽

Venous Drainage ◽

Endovascular Management ◽

Arteriovenous Fistulas ◽

Sagittal Sinus ◽

Dural Arteriovenous Fistulas ◽

Complete Obliteration ◽

Cortical Venous Drainage ◽

Transvenous Approach

Superior sagittal sinus (SSS) dural arteriovenous fistulas (DAVFs) are rare and present unique challenges to treatment. Complex, often bilateral, arterial supply and involvement of large volumes of eloquent cortical venous drainage may necessitate multimodality therapy such as endovascular, microsurgical, and stereotactic radiosurgery techniques. The authors present a complex SSS DAVF associated with an occluded/severely stenotic SSS. The patient underwent a successful endovascular transvenous approach with complete obliteration of the SSS. The authors discuss the management challenges faced on this case.The video can be found here: https://youtu.be/-rztg0_cBXY.

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