Benign cranial dural arteriovenous fistulas: outcome of conservative management based on the natural history of the lesion

2002 ◽  
Vol 97 (4) ◽  
pp. 767-770 ◽  
Author(s):  
Junichiro Satomi ◽  
J. MARC C. van Dijk ◽  
Karel G. Terbrugge ◽  
Robert A. Willinsky ◽  
M. Christopher Wallace
Keyword(s):  
Conservative Management ◽  
Venous Drainage ◽  
Initial Assessment ◽  
Benign Condition ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Tolerable Level ◽  
Fine Print

Object. Cranial dural arteriovenous fistulas (DAVFs) can be classified into benign or aggressive, based on their patterns of venous drainage. A benign condition requires the absence of cortical venous drainage (CVD). The clinical and angiographic features of a consecutive single-center group of 117 patients harboring benign cranial DAVFs were evaluated over time to validate the behavior and appropriate management of these lesions. Methods. At the initial assessment four patients were asymptomatic. Two infants presented with congestive heart failure. All other patients presented with other benign symptoms: chronic headache, bruit, or orbital phenomena. Observational management was instituted in 73 patients (62%). Intolerable bruit or ophthalmological sequelae were deemed indications for palliative embolization in 43 patients and surgical treatment in one patient. A median follow-up period of 27.9 months (range 1 month—17.5 years) was available in 112 patients (95.7%), among whom repeated angiography was performed in 50. Overall, observational and palliative management resulted in a benign and tolerable level of disease in 110 (98.2%) of 112 cases. In two cases managed conservatively CVD developed. In both of these cases the conversion from benign to aggressive DAVF was associated with spontaneous progressive thrombosis of venous outlets. Conclusions. The disease course of a cranial DAVF without CVD is indeed benign, obviating the need for a cure of these lesions. Symptoms are well tolerated with either observation or palliative treatment. After a long-term follow-up review of 68 patients, this conservative management resulted in a benign and tolerable level of disease in 98.5% of cases. It is noteworthy, however, that a benign DAVF carries a 2% risk of developing CVD, mandating close clinical follow-up review in such cases and renewed radiological evaluation in response to any deterioration in the patient's condition.

Surgical interruption of intradural draining vein as curative treatment of spinal dural arteriovenous fistulas

1995 ◽  
Vol 82 (2) ◽  
pp. 196-200 ◽  
Author(s):  
John K. B. Afshar ◽  
John L. Doppman ◽  
Edward H. Oldfield
Keyword(s):  
Arterial Occlusion ◽  
Venous Drainage ◽  
Curative Treatment ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Flow Through ◽  
Spinal Dural Arteriovenous Fistulas ◽  
Fine Print

✓ To establish if interruption of the intradural draining spinal vein or surgical excision are curative treatments for spinal dural arteriovenous fistulas (AVFs), the medical records and radiographic studies of 19 patients with spinal dural AVFs and progressive myelopathy were reviewed. Spinal arteriograms were obtained before and within 2 weeks after surgery in 19 patients, and after a delay of 4 months or more in 11 patients. The mean clinical and arteriographic follow up was at 37 and 35 months, respectively. In the 11 patients who underwent excision of the dural AVF there was no evidence of a residual lesion upon immediate or delayed postoperative arteriography. Surgery in eight patients consisted of simple interruption of the intradural draining vein as it entered the subarachnoid space. In six of these patients the vein draining the AVF intrathecally provided the only venous drainage of the AVF. In these six patients there was no immediate (six of six) or delayed (four of six) arteriographic evidence of residual or recurrent flow through the AVF. Two patients had an AVF with both intra- and extradural venous drainage; after intradural division of the draining vein there was residual flow through the AVF into the extradural venous system. In one of these two patients intrathecal venous drainage was reestablished, which required additional therapy. In the other patient the extradural AVF spontaneously thrombosed and was not evident on delayed follow-up arteriography. In patients with spinal dural AVFs with only intrathecal medullary venous drainage, which includes most patients with these lesions, surgical interruption of the intradural draining vein provides lasting and curative treatment. In patients with both intra- and extradural drainage of the AVF, complete excision of the fistula or interruption of the intra- and extradural venous drainage of the fistula is indicated. In patients in whom a common vessel supplies the spinal cord and the dural AVF, simple surgical interruption of the vein draining the AVF is the treatment of choice, as it provides lasting obliteration of the fistula and it is the only treatment that does not risk arterial occlusion and cord infarction. Simple interruption of the venous drainage of a spinal dural AVF provides lasting occlusion of the fistula, as it does for cranial dural AVFs, if all pathways of venous drainage are interrupted. This result provides further evidence that the venous approach to the treatment of dural AVFs can be used successfully.

Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses

2001 ◽  
Vol 94 (6) ◽  
pp. 886-891 ◽  
Author(s):  
Jonathan A. Friedman ◽  
Bruce E. Pollock ◽  
Douglas A. Nichols ◽  
Deborah A. Gorman ◽  
Robert L. Foote ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Transarterial Embolization ◽  
Symptom Relief ◽  
Related Complication ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Lost To Follow Up ◽  
Fine Print

Object. Most dural arteriovenous fistulas (DAVFs) of the transverse and sigmoid sinuses do not have angiographically demonstrated features associated with intracranial hemorrhage and, therefore, may be treated nonsurgically. The authors report their experience using a staged combination of radiosurgery and transarterial embolization for treating DAVFs involving the transverse and sigmoid sinuses. Methods. Between 1991 and 1998, 25 patients with DAVFs of the transverse and/or sigmoid sinuses were treated using stereotactic radiosurgery; 22 of these patients also underwent transarterial embolization. Two patients were lost to follow-up review. Clinical data, angiographic findings, and follow-up records for the remaining 23 patients were collected prospectively. The mean duration of clinical follow up after radiosurgery was 50 months (range 20–99 months). The 18 women and five men included in this series had a mean age of 57 years (range 33–79 years). Twenty-two (96%) of 23 patients presented with pulsatile tinnitus as the primary symptom; two patients had experienced an earlier intracerebral hemorrhage (ICH). Cognard classifications of the DAVFs included the following: I in 12 patients (52%), IIa in seven patients (30%), and III in four patients (17%). After treatment, symptoms resolved (20 patients) or improved significantly (two patients) in 96% of patients. One patient was clinically unchanged. No patient sustained an ICH or irradiation-related complication during the follow-up period. Seventeen patients underwent follow-up angiographic studies at a mean of 21 months after radiosurgery (range 11–38 months). Total or near-total obliteration (> 90%) was seen in 11 patients (65%), and more than a 50% reduction in six patients (35%). Two patients experienced recurrent tinnitus and underwent repeated radiosurgery and embolization at 21 and 38 months, respectively, after the first procedure. Conclusions. A staged combination of radiosurgery and transarterial embolization provides excellent symptom relief and a good angiographically verified cure rate for patients harboring low-risk DAVFs of the transverse and sigmoid sinuses. This combined approach is a safe and effective treatment strategy for patients without angiographically determined risk factors for hemorrhage and for elderly patients with significant comorbidities.

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

2002 ◽  
Vol 96 (5) ◽  
pp. 823-829 ◽  
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.

Combining endovascular and neurosurgical treatments of high-risk dural arteriovenous fistulas in the lateral sinus and the confluence of the sinuses

1999 ◽  
Vol 90 (2) ◽  
pp. 289-299 ◽  
Author(s):  
Katsuya Goto ◽  
Prijo Sidipratomo ◽  
Noboru Ogata ◽  
Toru Inoue ◽  
Haruo Matsuno
Keyword(s):  
High Risk ◽  
Signs And Symptoms ◽  
Venous Drainage ◽  
Complex Nature ◽  
Lateral Sinus ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Diffuse Brain Swelling ◽  
Fine Print

Object. The authors describe the use of a systemic approach to treat dural arteriovenous fistulas (DAVFs) in the lateral sinus and the confluence of sinuses in 17 patients who presented with signs and symptoms related to intracranial hemorrhage, infarction, and diffuse brain swelling.Methods. Angiographic examination revealed three different types of DAVFs in these high-risk patients: 1) extremely high flow DAVF not associated with sinus occlusion or leptomeningeal retrograde venous drainage (LRVD); 2) localized DAVF with exclusive LRVD and without sinus occlusion; and 3) diffuse DAVF with sinus occlusion and LRVD. Because of the complex nature of these lesions, the authors adopted a staged protocol in which they combined endovascular and surgical treatments.Conclusions. The authors believe that by close collaboration between endovascular therapists and vascular neurosurgeons, high-risk DAVFs in the lateral sinus and the confluence of sinuses can be successfully managed without treatment-related morbidity and mortality.

Surgical and endovascular treatment of spinal dural arteriovenous fistulas: long-term disability assessment and prognostic factors

2001 ◽  
Vol 94 (2) ◽  
pp. 199-204 ◽  
Author(s):  
Joon K. Song ◽  
Fernando Viñuela ◽  
Y. Pierre Gobin ◽  
Gary R. Duckwiler ◽  
Yuichi Murayama ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
Mr Imaging ◽  
Symptom Onset ◽  
Disability Score ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas ◽  
Fine Print

Object. The authors assessed clinical outcomes of patients with treated spinal dural arteriovenous fistulas (DAVFs) and investigated prognostic factors. Methods. Thirty consecutive patients with spinal DAVFs were treated at the authors' institution during the past 15 years: seven underwent surgery; seven underwent surgery after failed embolization; and 16 underwent embolization alone. The outcomes of gait and micturition disability were analyzed. Follow up averaged 3.4 years (range 1 month–11.8 years). Age, duration of symptoms, pre- and postintervention magnetic resonance (MR) imaging findings, and preintervention disability were correlated with outcome. Seventeen patients (57%) experienced improved gait, 12 (40%) were unchanged, and one (3%) was worse. In 11 patients (37%) micturition function was improved, in 15 (50%) it was unchanged, and in four (13%) it was worse. Gait disability, as measured by the Aminoff—Logue Scale, was significantly improved after treatment, from 3.4 ± 1.4 (average ± standard deviation) to 2.7 ± 1.5 (p = 0.007). Mean micturition disability scores decreased, but not significantly, from 1.9 ± 1 to 1.6 ± 1.1 (p = 0.20). Preintervention gait disability was not associated with improvement except for patients with Aminoff—Logue Scale Grade 4 disability (eight of nine improved; p = 0.024). For patients treated within 13 months of symptom onset, mean micturition disability decreased (p = 0.035). No association was found between clinical improvement and age, a symptom duration less than 30 months, or pre- and postintervention MR imaging—documented spinal cord edema. Conclusions. Spinal DAVF treatment significantly improved patients' mean gait disability score by almost one grade at last follow up. The mean micturition disability score was not significantly improved, unless treatment was performed within 13 months of symptom onset. Longer and more uniform follow-up study is needed to determine if improved and stabilized clinical outcomes are sustained.

Embolization of spinal dural arteriovenous fistulas: importance of occlusion of the draining vein

2005 ◽  
Vol 2 (5) ◽  
pp. 580-583 ◽  
Author(s):  
Korné Jellema ◽  
Menno Sluzewski ◽  
Willem Jan van Rooij ◽  
Cees C. Tijssen ◽  
Guus N. Beute
Keyword(s):  
Treatment Option ◽  
Additional Treatment ◽  
The Other ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas ◽  
Fine Print

Object. The aim of this study was to assess whether glue-induced occlusion of the draining vein predicts permanent closure of the fistula following embolization of spinal dural arteriovenous fistulas (SDAVFs). Methods. Between 1994 and 2004, 36 consecutive patients with an SDAVF were treated at the authors' institution. Twelve patients underwent surgery and 24 glue-based embolization. In 12 of 24 embolization procedures the draining vein was occluded and no recurrence or persistent fistula was seen during the follow-up period. In the other 12 patients the glue had not reached the draining vein and in eight of these the fistula recurred, necessitating additional treatment. Conclusions. In embolization of SDAVFs penetration of the glue into the draining vein predicts permanent closure of the fistula. When penetration of the glue into the draining vein can be expected, embolization is the preferred treatment option. In other cases surgery should be the treatment of choice.

Multiplicity of dural arteriovenous fistulas

2002 ◽  
Vol 96 (1) ◽  
pp. 76-78 ◽  
Author(s):  
J. Marc C. Van Dijk ◽  
Karel G. TerBrugge ◽  
Robert A. Willinsky ◽  
M. Christopher Wallace
Keyword(s):  
Venous Drainage ◽  
Entire Group ◽  
Additional Risk ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Bilateral Involvement ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Drainage ◽  
Risk Of Hemorrhage ◽  
Fine Print

Object. Dural arteriovenous fistulas (AVFs) are a well-known pathoanatomical and clinical entity. Excluding bilateral involvement of the cavernous sinus, multiple dural AVFs are rare, with isolated reports in the literature. The additional risk associated with multiplicity is unknown, although it has been claimed that there is a greater risk of hemorrhage at presentation. In a group of 284 patients with dural AVFs consecutively treated at a single center, the occurrence of multiplicity is investigated and its risk factors for hemorrhage are identified. Methods. Among the 284 patients with both cranial and spinal dural AVFs, 20 patients with multiple fistulas were found. Nineteen (8.1%) of 235 patients with cranial AVFs had multiple cranial fistulas, and one (2%) of 49 patients with spinal AVFs harbored two spinal fistulas. Twelve patients were found to have a lesion at two separate sites, seven patients had them at three locations, and one patient had four fistulas, each at a different site. In the subgroup with multiple AVFs the percentage of hemorrhage at presentation was three times higher than in the entire group (p = 0.01). Cortical venous drainage in cranial fistulas was present in 84% of patients with multiple lesions compared with 46% of patients with solitary lesions (p < 0.005). Conclusions. Multiple dural AVFs are not rare. In this group of 284 patients it was found in 8.1% of all patients with cranial dural AVFs. Multiplicity was associated with a higher percentage of cortical venous drainage, a pattern of drainage reportedly yielding a higher risk for hemorrhage.

Direct packing of the isolated sinus in patients with dural arteriovenous fistulas of the transverse—sigmoid sinus

1998 ◽  
Vol 88 (3) ◽  
pp. 449-456 ◽  
Author(s):  
Shunro Endo ◽  
Naoya Kuwayama ◽  
Akira Takaku ◽  
Michiharu Nishijima
Keyword(s):  
Transarterial Embolization ◽  
Blood Gases ◽  
Venous Drainage ◽  
Sigmoid Sinus ◽  
Blood Gas ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Sinus Pressure ◽  
Fine Print

Object. The goal of this study was to evaluate the efficacy of direct packing of the isolated sinus (occluded both distally and proximally) in patients with dural arteriovenous fistulas (AVFs) of the transverse—sigmoid sinus. Methods. Eight patients were included in this study. There were seven men and one woman, ranging in age from 47 to 75 years (mean 60.4 years). Five patients presented with intracranial hemorrhage or venous infarction, one with convulsions, and two with pulsatile tinnitus. Prominent retrograde cortical venous drainage due to sinus isolation was angiographically demonstrated in all patients. All patients were treated by a small craniotomy and direct sinus packing with microcoils; the procedure was performed with the aid of digital subtraction angiography. Five patients were pretreated with transarterial embolization to reduce arterial inflow before the procedure, and intrasinus pressure and sinus blood gases were monitored throughout the operation. Postsurgery, the dural AVF was completely obliterated in all patients. The sinus pressure was 29 to 58% of systemic blood pressure, and sinus blood gas levels were purely arterial before packing. There was no morbidity related to direct sinus packing; however, one patient died as a result of acute myocardial infarction. Over a follow-up period ranging from 1 to 5 years, a faint asymptomatic dural AVF recurred in one patient on the cortex adjacent to the occluded sinus but regressed spontaneously within 1 year. Conclusions. Direct sinus packing was found to be highly effective for the treatment of dural AVFs that empty into the isolated sinus. Measurement of changes in sinus pressure and sinus blood gas levels was useful for monitoring the progress of direct sinus packing.

Selective disconnection of cortical venous reflux as treatment for cranial dural arteriovenous fistulas

2004 ◽  
Vol 101 (1) ◽  
pp. 31-35 ◽  
Author(s):  
J. Marc C. van Dijk ◽  
Karel G. TerBrugge ◽  
Robert A. Willinsky ◽  
M. Christopher Wallace
Keyword(s):  
Dural Sinus ◽  
Venous Reflux ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Reflux ◽  
Sinus Drainage ◽  
Fine Print

Object. A single-institution series of 119 consecutive patients with a dural arteriovenous fistula (DAVF) and cortical venous reflux was reviewed to assess the overall clinical outcome of multidisciplinary management after long-term follow up. The selective disconnection of the cortical venous reflux compared with the obliteration of the entire DAVF was evaluated. Methods. Dural arteriovenous fistulas in patients in this series were diagnosed between 1984 and 2001, and treatment was instituted in 102 of them. The outcome of adequately treated patients was compared with that of a control group consisting of those with persistent cortical venous reflux and with data found in the literature. In cases of combined dural sinus drainage and cortical venous reflux, a novel treatment concept of selective disconnection of the cortical venous reflux that left the sinus drainage intact, and thus converted the aggressive DAVF into a benign lesion, was evaluated. Endovascular treatment, which was instituted initially in 78 patients, resulted in an obliteration or selective disconnection in 26 (25.5%) of 102 cases. In 70 cases (68.6%) the DAVFs were surgically obliterated or disconnected. In six cases (5.9%), patients were left with persistent cortical venous reflux. No lasting complications were noted in this series. Follow-up angiography confirmed a durable result in 94 (97.9%) of 96 adequately treated cases, at a mean follow up of 27.6 months (range 1.4–138.3 months). Selective disconnection was performed in 23 DAVFs with combined sinus drainage and cortical venous reflux. These patients' long-term outcomes were equal to those with obliterated DAVFs, and the complication rate was lower. Conclusions. Considering the ominous course of DAVFs with patent cortical venous reflux, multidisciplinary treatment of these lesions is highly effective and the complication rate is low. Selective disconnection provides a valid treatment option of DAVFs with combined dural sinus drainage and cortical venous reflux, as has been shown in cranial DAVFs with direct cortical venous reflux.

Use of a wedged microcatheter for curative transarterial embolization of complex intracranial dural arteriovenous fistulas: indications, endovascular technique, and outcome in 21 patients

2003 ◽  
Vol 98 (3) ◽  
pp. 498-506 ◽  
Author(s):  
Peter Kim Nelson ◽  
Stephen M. Russell ◽  
Henry H. Woo ◽  
Anthony J. G. Alastra ◽  
Danko V. Vidovich
Keyword(s):  
Transarterial Embolization ◽  
Visual Field Loss ◽  
Venous Drainage ◽  
Venous Access ◽  
Definitive Treatment ◽  
Content Type ◽  
Cavernous Sinus Syndrome ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Fine Print

Object. The aim of this study was to describe the application of a novel transarterial approach to curative embolization of complex intracranial dural arteriovenous fistulas (DAVFs). This technique is particularly useful in patients harboring high-grade DAVFs with direct cortical venous drainage or for whom transvenous coil embolization is not possible because of limited sinus venous access to the fistula site due to thrombosis or stenotic changes. Methods. Twenty-three DAVFs in 21 patients were treated using a transarterial N-butyl cyanoacrylate (NBCA) embolization technique with the aid of a wedged catheter. In all patients, definitive treatment involved two critical steps: 1) a microcatheter was wedged within a feeding artery, establishing flow-arrest conditions within the catheterized vessel distal to the microcatheter tip; and 2) NBCA was injected under these resultant flow-arrest conditions across the pathological arteriovenous connection and into the immediate draining venous apparatus, definitively occluding the fistula. Patient data were collected in a retrospective manner by reviewing office and inpatient charts and embolization reports, and by directly analyzing all procedural and diagnostic angiograms. Eight patients presented with the principal complaint of tinnitus/bruit, five with intracranial hemorrhage, four with cavernous sinus syndrome, and one each with seizures, ataxia, visual field loss, and hiccups. The parent (recipient) venous structure of the DAVFs in this study included 11 leptomeningeal veins, eight transverse/sigmoid sinuses, three cavernous sinuses, and one sphenoparietal sinus. The NBCA permeated the arteriovenous shunt, perifistulous network, and proximal draining vein in all DAVFs. Occlusion was confirmed on postembolization angiography studies. No complication occurred in any patient in this series. There has been no recurrence during a mean follow up of 18.7 months (range 2–46 months). Conclusions. Transarterial NBCA embolization with the aid of a wedged catheter in flow-arrest conditions is a safe and an effective treatment for intracranial DAVFs.

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