Gamma knife surgery for dural arteriovenous shunts: 25 years of experience

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The aim of this study was to assess the clinical efficacy of gamma knife surgery (GKS) in the treatment of dural arteriovenous shunts (DAVSs).


From a database of more than 1600 patients with intracranial arteriovenous shunts that had been treated with GKS, the authors retrospectively and prospectively identified 53 patients with 58 DAVSs from the period between 1978 and 2003. Four patients were lost to follow-up evaluation and were excluded from the series. Thus, this study is based on the remaining 49 patients with 52 DAVSs. Thirty-six of the shunts drained into the cortical venous system, either directly or indirectly, and 22 of these were associated with intracranial hemorrhage on patient presentation. The mean prescription radiation dose was 22 Gy (range 10–28 Gy).

All patients underwent a clinical follow-up examination. In 41 cases of DAVS a follow-up angiography study was performed. At the 2-year follow-up visit, 28 cases (68%) had angiographically proven obliteration of the shunt and in another 10 cases (24%) there was significant flow regression. Three shunts remained unchanged.

There was one immediate minor complication related to the administration of radiation. Furthermore, one patient had a radiation-induced complication 10 years after treatment, although she recovered completely. There was one posterior fossa bleed 2 months after radiosurgery; a hematoma, as well as a lesion, was evacuated, and the patient recovered uneventfully. A second patient had an asymptomatic occipital hemorrhage approximately 6 months postradiosurgery.

The clinical outcome after GKS was significantly better than that in patients with naturally progressing shunts (p < 0.01, chi-square test); figures on the latter have been reported previously.


Gamma knife surgery is an effective treatment for DAVSs, with a low risk of complications. Major disadvantages of this therapy include the time elapsed before obliteration and the possibility that not all shunts will be obliterated. Cortical venous drainage from a DAVS, a risk factor for intracranial hemorrhage, is therefore a relative contraindication. Consequently, GKS can be used in the treatment of both benign DAVSs with subjectively intolerable bruit and aggressive DAVSs not responsive to endovascular treatment or surgery.

Abbreviations used in this paper:AVM = arteriovenous malformation; CT = computerized tomography; CVD = cortical venous drainage; DAVS = dural arteriovenous shunt; GKS = gamma knife surgery; MR = magnetic resonance.

Article Information

Address reprint requests to: Michael Söderman, M.D., Ph.D., Department of Neuroradiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    External carotid artery injection angiograms. A: Subtracted image, lateral view, obtained before GKS in a patient with a DAVS in the wall of the left transverse sinus, demonstrating CVD into a large temporal vein. This patient had pulse-synchronous bruit well before she was first examined in 1993, although she had not demonstrated bleeding. B: Stereotactic subtracted image, posteroanterior view. The black outline indicates the shunt zone of the DAVS. C: Stereotactic unsubtracted image, posteroanterior view. The blue outline indicates the shunt zone of the DAVS; the yellow outline, the 55% isodose line; and the red crosses, the four gamma knife shots applied with the 8-mm collimator. D: Stereotactic subtracted image, lateral view. The black outline indicates the shunt zone of the DAVS. E: Stereotactic unsubtracted image, lateral view. The blue outline, yellow outline, and red crosses indicate the same features as in panel C. Treatment was performed using a 25-Gy prescription dose, and the maximal dose was 42 Gy. The patient underwent GKS for the first time in 1996, and the bruit disappeared 14 days after treatment. F: Subtracted angiogram obtained 2 years after treatment, showing obliteration of the DAVS.

  • View in gallery

    Upper Left: External carotid artery injection stereotactic subtracted angiogram, lateral view, obtained in a patient with a DAVS in the medial wall of the middle fossa, demonstrating CVD in the basal vein of Rosenthal. The white outline indicates the shunt zone. Right: Axial stereotactic T1-weighted MR image demonstrating super-imposed delineation (blue outline) from stereotactic angiography studies. The red lines indicate projection lines; and the yellow outline, the 25-Gy isodose line. This patient had had pulse-synchronous bruit since approximately 6 months before she was first examined, although she had not demonstrated bleeding. The bruit disappeared 8 weeks after GKS with a 25-Gy prescription dose. Lower Left: External carotid artery injection subtracted angiogram, lateral view, obtained 10 weeks after GKS, showing obliteration of the DAVS.

  • View in gallery

    Upper Left: External carotid artery injection subtracted angiogram, lateral view, obtained in a patient with a high-flow DAVS in the vein of Galen and straight sinus, demonstrating CVD most prominent into the basal vein of Rosenthal. Upper Right: Vertebral artery injection stereotactic angiogram, posteroanterior view, demonstrating the shunt zone (black outline). Lower Left: Vertebral artery injection stereotactic angiogram, lateral view, depicting the shunt zone. Gamma knife surgery was performed using 20-Gy prescription dose to the 50% isodose line. In addition, the patient was subjected to transarterial embolization of the DAVS. Lower Right: Sagittal T1-weighted MR image obtained 2 years post-GKS, showing an unchanged DAVS, tonsillar herniation, and ventricular enlargement. Despite signs of increased intracranial pressure, the patient was mentally intact during the 2-year follow-up period. The main symptom was bruit, which was almost unaffected by the treatment.


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