Stereotactic Radiosurgery with or without Embolization for Intracranial Dural Arteriovenous Fistulas

Abstract

Treatment options for symptomatic dural arteriovenous fistulas (DAVFs) include surgery, embolization and stereotactic radiosurgery (SRS). We reviewed our DAVF experience at the University of Pittsburgh and assessed the role of SRS. We evaluated 40 consecutive patients who underwent Gamma Knife SRS for 44 DAVFs. Twenty-eight patients had upfront SRS before or after embolization performed at our institution, and 12 patients underwent delayed SRS for recurrent or residual DAVFs after initial embolization. The median SRS target volume was 2.0 cm3, and the median marginal dose was 21.0 Gy. At a median follow-up of 45 months (range, 23-116 months), a total of 28 patients with 32 DAVFs had obliteration. The obliteration rate was 83% for patients who had upfront SRS and embolization. The obliteration rate was lower (67%) for patients managed with SRS alone. The obliteration rate was 71% for patients who had delayed SRS for recurrent or residual DAVFs following prior embolization. In our experience cavernous/carotid fistulas were associated with higher rates of obliteration and symptomatic improvement compared to transverse/sigmoid sinus region fistulas. Our experience suggests that successful DAVF obliteration is possible in most patients with upfront SRS in conjunction with embolization. SRS alone is an effective treatment for selected patients with a small-volume, low-risk DAVF.

Surgical access on the superior ophthalmic vein to the cavernous sinus dural fistula for embolization

“…Pan et al 24 reported their series of 41 patients treated by stereotactic radiosurgery for CSDF with a 90% obliteration rate. Yang and colleagues25 showed similar results in their cohort of 40 patients treated by stereotactic radiosurgery. They also found that CSDF was associated with higher rates of occlusion (p=0.012) and improvement in symptoms (p=0.010) than was transverse–sigmoid sinus fistula.…”

Standard and Guidelines: Intracranial Dural Arteriovenous Shunts

“…SRS can also be a treatment option for patients in whom endovascular or open surgical treatments are deemed to carry high procedure-related risks and in patients with residual fistulas following prior treatments. SRS has shown reasonably good obliteration rates; the complete obliteration rates of DAVS after SRS was about 68% with SRS alone and 83% in SRS combined with endovascular treatment 59 60. Complication rates were very low with post-SRS hemorrhage, neurologic deficit, and mortality rates of 1.2%, 1.3%, and 0.3%, respectively 60.…”

Management, risk factors and outcome of cranial dural arteriovenous fistulae: a single-center experience

“…The therapeutic delay of stereotactic radiosurgery would be unacceptable for most patients except those with very high peri-procedural risks. Stereotactic radiosurgery may be a reasonable alternative in asymptomatic patients and those that carry a high periprocedural risk, but this has to be proven by further studies [38].…”