Endovascular Treatment of Intracranial Dural Arteriovenous Fistulas with Cortical Venous Drainage: New Management Using Onyx

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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Gamma Knife Radiosurgery: The Gold Standard Treatment for Intracranial Dural Arteriovenous Fistulas without Cortical Venous Drainage

Neurology India ◽

10.4103/0028-3886.293482 ◽

2020 ◽

Vol 68 (4) ◽

pp. 815

Author(s):

Deepak Agrawal ◽

Hardik Sardana ◽

Niveditha Manjunath

Keyword(s):

Gamma Knife ◽

Gold Standard ◽

Standard Treatment ◽

Gamma Knife Radiosurgery ◽

Venous Drainage ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Cortical Venous Drainage

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Intracranial Dural Arteriovenous Fistulas with Cortical Venous Drainage: Radiosurgery as an effective alternative treatment

World Neurosurgery ◽

10.1016/j.wneu.2021.11.113 ◽

2021 ◽

Author(s):

Hardik Sardana ◽

Deepak Agrawal ◽

Bhavya Pahwa ◽

M.M. Singh ◽

N.K. Mishra ◽

...

Keyword(s):

Alternative Treatment ◽

Venous Drainage ◽

Effective Alternative ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Cortical Venous Drainage

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Cranial dural arteriovenous fistulas: modification of angiographic classification scales based on new natural history data

Neurosurgical FOCUS ◽

10.3171/2009.2.focus0928 ◽

2009 ◽

Vol 26 (5) ◽

pp. E14 ◽

Cited By ~ 94

Author(s):

Gregory J. Zipfel ◽

Manish N. Shah ◽

Daniel Refai ◽

Ralph G. Dacey ◽

Colin P. Derdeyn

Keyword(s):

High Risk ◽

Intracerebral Hemorrhage ◽

Clinical Symptoms ◽

Venous Drainage ◽

Risk Groups ◽

Neurological Deficits ◽

Neurological Injury ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Cortical Venous Drainage

This article presents a modification to the existing classification scales of intracranial dural arteriovenous fistulas based on newly published research regarding the relationship of clinical symptoms and outcome. The 2 commonly used scales, the Borden-Shucart and Cognard scales, rely entirely on angiographic features for categorization. The most critical anatomical feature is the identification of cortical venous drainage (CVD; Borden-Shucart Types II and III and Cognard Types IIb, IIa + b, III, IV, and V), as this feature identifies lesions at high risk for future hemorrhage or ischemic neurological injury. Yet recent data has emerged indicating that within these high-risk groups, most of the risk for future injury is in the subgroup presenting with intracerebral hemorrhage or nonhemorrhagic neurological deficits. The authors have defined this subgroup as symptomatic CVD. Patients who present incidentally or with symptoms of pulsatile tinnitus or ophthalmological phenomena have a less aggressive clinical course. The authors have defined this subgroup as asymptomatic CVD. Based on recent data the annual rate of intracerebral hemorrhage is 7.4–7.6% for patients with symptomatic CVD compared with 1.4–1.5% for those with asymptomatic CVD. The addition of asymptomatic CVD or symptomatic CVD as modifiers to the Borden-Shucart and Cognard systems improves their accuracy for risk stratification of patients with high-grade dural arteriovenous fistulas.

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Spontaneous Closure of Cerebral Dural Arteriovenous Fistulas with Direct Cortical Venous Drainage

Interventional Neuroradiology ◽

10.1177/159101990901500316 ◽

2009 ◽

Vol 15 (3) ◽

pp. 359-362 ◽

Cited By ~ 11

Author(s):

M. Voormolen ◽

K. Geens ◽

L. Van Den Hauwe ◽

P.M. Parizel

Keyword(s):

Contrast Medium ◽

Venous Drainage ◽

Spontaneous Closure ◽

Fistula Closure ◽

Selective Angiography ◽

Cortical Vein ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Cortical Venous Drainage

We describe two rare cases of spontaneous closure of cerebral dural arteriovenous fistulas (DAVFs) with a small nidus and draining directly in a single cortical vein with several ectasias. Eighteen previously published cases of spontaneous closure of cerebral DAVF comprised more benign fistula types. In literature, several explanations for DAVF occlusion have been proposed. We hypothesize that, in addition to the known causes, the specific contrast medium used during the diagnostic selective angiography might have played a role in the thrombosis and subsequent fistula closure.

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Transvenous Approach to Intracranial Dural Arteriovenous Fistula (Cognard V): A Treatment Option

Interventional Neuroradiology ◽

10.1177/159101991101700117 ◽

2011 ◽

Vol 17 (1) ◽

pp. 108-114 ◽

Cited By ~ 4

Author(s):

S. Aixut Lorenzo ◽

A. Tomasello Weitz ◽

J. Blasco Andaluz ◽

L. Sanroman Manzanera ◽

J.M. Macho Fernández

Keyword(s):

Endovascular Treatment ◽

Clinical Symptoms ◽

Venous Drainage ◽

Complete Disappearance ◽

Venous Flow ◽

Arteriovenous Fistulas ◽

Collateral Arteries ◽

Dural Arteriovenous Fistulas ◽

Type V ◽

Transvenous Approach

The endovascular technique is the gold standard treatment in dural arteriovenous fistulas. Due to the limited number of series published it is difficult to create rigid guidelines in terms of the best endovascular treatment approach. Treatment must be tailored to each particular case, but it is important to keep in mind that the possibility of treating a type V dAVF by the transvenous approach should not be discarded. In selected cases the transvenous approach may be helpful to increase the chance of success in the endovascular treatment of type V dAVF. We describe a patient in whom the first arterial treatment failed to achieve occlusion of the fistulous point with the glue. Clinical symptoms improved due to the diminished flow at the fistula after the first embolization but as soon as collateral arteries were recruited by the fistula, spinal cord venous drainage impairment led to symptoms recurrence. Transvenous access allowed us to close the fistula completely in one only session with a complete disappearance of the pathologically inverted perimedullary venous flow.

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