Gamma Knife Radiosurgery for Dural Arteriovenous Fistulas

Cifarelli, Christopher P.; Kaptain, George J.; Yen, Chun-Po; Schlesinger, David; Sheehan, Jason P.

doi:10.1227/neu.0b013e3181eff6f7

Cited by 71 publications

(57 citation statements)

References 23 publications

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“…Factors found by the included studies to be significantly associated with obliteration are as follows: CS DAVFs, Borden Type I DAVFs, DAVFs without CVD, hemorrhage at presentation, target volume < 1.5 ml, and Cognard Types III or IV DAVFs. 7,16,51 Factors found to be nonsignificant are as follows: patient age and sex, prior treatments, DAVF location and size, DAVFs with multiple arteriovenous connections versus DAVFs with single arteriovenous connections, and minimal radiation dose delivered to DAVFs. number of other studies have investigated the use of SRS for treating DAVFs in other locations, with variable rates of success.…”

Section: Outcomes For Davfs With Cvd Versus Davfs Without Cvdmentioning

confidence: 99%

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Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

Chen¹,

Lee

Ding³

et al. 2015

JNS

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C urrent treatment strategies for intracranial dural arteriovenous fistulas (DAVFs) include microsurgical ligation, transarterial or transvenous embolization, stereotactic radiosurgery (SRS), and various combinations of these therapeutic options. Endovascular therapy, most commonly performed via transvenous routes, has become the preferred treatment approach for DAVFs. 27,44,48 Due to the immediate obliteration that can be achieved with endovascular or surgical occlusion, SRS is typically reserved for lesions that cannot be obliterated with endovascular or surgical approaches, or for patients who pose a high surgical risk due to medical comorbidities. Therefore, published SRS series for DAVFs remain relatively few and comprise mostly retrospective, single-center studies.In this systematic review, we evaluate the obliteration rate of DAVFs in patients treated with SRS. We also compare obliteration rates between cavernous sinus (CS) and noncavernous sinus (NCS) DAVFs, and between DAVFs with and without cortical venous drainage (CVD), by using available data in the literature. Methods inclusion CriteriaIn our attempt to balance between the largest possible patient population and a relatively homogeneous cohort, the following inclusion criteria for this systematic review were devised: 1) the study must contain at least 5 patients abbreviatioNs AVM = arteriovenous malformation; CS = cavernous sinus; CVD = cortical venous drainage; DAVF = dural arteriovenous fistula; GKS = Gamma Knife surgery; LINAC = linear accelerator; NCS = noncavernous sinus; SRS = stereotactic radiosurgery; TSS = transverse and sigmoid sinus. 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 D...

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Section: Outcomes For Davfs With Cvd Versus Davfs Without Cvdmentioning

confidence: 99%

“…7,12,22,23,35,39,51 Although endovascular embolization may provide immediate symptomatic relief and reduction of hemorrhage risk, the treatment may not afford longterm cure in cases of subtotal obliteration or delayed recanalization. 24 Therefore, SRS serves as a complementary treatment by potentially increasing the likelihood of permanent DAVF occlusion.…”

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confidence: 99%

Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

Chen¹,

Lee

Ding³

et al. 2015

JNS

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“…7 In this study, the obliteration rate was 75% for DAVFs smaller than or equal to 10 mm, decreasing to 64% for those larger than 10 mm. Indeed, this study concluded that the 2 main statistically significant factors negatively influencing DAVF obliteration were CVD and target size greater than 20 mm.…”

mentioning

confidence: 48%

“…Although one study did not demonstrate a significant difference in obliteration rates for SRS in conjunction with embolization, 7 another demonstrated greater obliteration rates when these 2 modalities were used in conjunction.…”

Section: 35mentioning

confidence: 90%

Stereotactic radiosurgery for cerebral dural arteriovenous fistulas

Gross

Ropper²,

Popp³

et al. 2012

FOC

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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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“…In the largest series by Cifarelli et al, 3 55 adults with dural AVFs were treated with GKS from 1989 to 2005 and angiographic obliteration was achieved in 54%-65% at 3 years. However, 5% of patients experienced a hemorrhage during the latency period from treatment to obliteration.…”

Section: Stereotactic Radiosurgerymentioning

confidence: 99%

Multimodal treatment strategies for complex pediatric cerebral arteriovenous fistulas: contemporary case series at Barrow Neurological Institute

Zaidi¹,

Kalani²,

Spetzler³

et al. 2015

PED

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OBJECT Pediatric cerebral arteriovenous fistulas (AVFs) are rare but potentially lethal vascular lesions. Management strategies for these lesions have undergone considerable evolution in the last decade with the advent of new endovascular, surgical, and radiosurgical technologies. This study sought to review current treatment strategies and long-term clinical outcomes at a high-volume cerebrovascular institute. METHODS A retrospective chart review was performed on patients with a diagnosis of cerebral AVF from 1999 to 2012. Patients with carotid-cavernous fistulas, vein of Galen malformations, and age > 18 years were excluded from final analysis. Medical history, surgical and nonsurgical treatment, and clinical outcomes were documented. Pre- and postoperative angiograms were analyzed to assess for obliteration of the fistula. RESULTS Seventeen patients with pial AVFs (29.4%), dural AVFs (64.7%), or mixed pial/dural AVFs (5.9%) were identified. The majority of lesions were paramedian (70.6%) and supratentorial (76.5%). The study population had a mean age of 6.4 years, with a slight male predominance (52.9%), and the most common presenting symptoms were seizures (23.5%), headaches (17.6%), congestive heart failure (11.7%), and enlarging head circumference (11.7%). Among patients who underwent intervention (n = 16), 56.3% were treated with endovascular therapy alone, 6.3% were treated with open surgery alone, and 37.5% required a multimodal approach. Overall, 93.8% of the treated patients received endovascular treatment, 43.8% received open surgery, and 12.5% received radiosurgery. Endovascular embolysates included Onyx (n = 5), N-butyl cyanoacrylate (NBCA; n = 4), or coil embolization (n = 7) with or without balloon assistance (n = 2). Complete angiographic obliteration was achieved in 87.5% at the last follow-up evaluation (mean follow-up 3.1 years). One infant with incomplete AVF obliteration died of congestive heart failure, and 1 patient with complete obliteration died of acute sinus thrombosis, with an overall complication rate of 18.8%. CONCLUSIONS Pediatric cerebral AVFs are challenging neurosurgical lesions. Although advancements in endovascular therapy in the last decade have greatly changed the natural course of this disease, a multidisciplinary approach remains necessary for a large subset of patients. Surgeon experience with a thorough analysis of preoperative imaging is paramount to achieving acceptable clinical outcomes.

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Gamma Knife Radiosurgery for Dural Arteriovenous Fistulas

Abstract: Gamma Knife radiosurgery is an effective adjunct therapy for dAVFs with persistence of flow after open neurosurgical resection or endovascular treatment while still maintaining a role in nonaggressive dAVFs not amenable to either surgery or embolization.

Cited by 71 publications

References 23 publications

Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

Stereotactic radiosurgery for cerebral dural arteriovenous fistulas

Multimodal treatment strategies for complex pediatric cerebral arteriovenous fistulas: contemporary case series at Barrow Neurological Institute

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