Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

Abstract

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...

A Retrospective Analysis of the Outcomes of Dural Arteriovenous Fistulas Treated with Gamma Knife Radiosurgery: A Single-Institution Experience

“…More recently, some authors reported the outcomes of DAVF treated with SRS as the primary treatment modality, and showed a relatively high obliteration rate in selected types, such as lowgrade DAVF [8,11,21,22]. In this study, treatment strategies were formulated based on clinical characteristics as well as angiographic findings, such as location, CVD, and the Borden/Cognard classification.…”

“…As a result, endovascular embolization has become the primary treatment for the majority of DAVFs in our institution [23,24]. Endovascular embolization may provide immediate symptomatic improvement and decreased hemorrhage risk; however, it carries a risk of incomplete obliteration or delayed recanalization [8,25]. SRS can be considered as an adjuvant treatment modality for residual DAVF or when there is poor vascular access.…”

“…Since it was first reported by Barcia-Salorio et al [7], a number of other studies have been reported. To date, SRS is typically considered an adjuvant treatment modality for patients who cannot be treated with surgery or embolization, or for patients with a high surgical risk [8]. Therefore, there are relatively few reported studies on SRS for DAVF compared with embolization or surgery studies.…”

Intracranial Dural Arteriovenous Fistulae

“…[85][86][87][88][89] A recent meta-analysis by Chen et al 88 including 19 studies and 729 patients who underwent GKS for DAVF demonstrated complete obliteration of 73% for fistulae involving the cavernous sinus, compared with 58% for lesions located at other sites. A higher obliteration rate was also noted for DAVF without CVD (75% versus 56%).…”

“…[85][86][87][88] Reported complication rates after GKS of DAVF have been low or even zero in some series, with a few isolated reports of induction of CVD after treatment. [85][86][87][88][89] However, the major drawback of GKS is the delay in fistula closure when this treatment modality is used alone. Consequently, GKS by itself may be inappropriate for DAVF that demonstrate aggressive behavior or high-risk angioarchitecture features.…”