Reconsidering an important subclass of high-risk dural arteriovenous fistulas for stereotactic radiosurgery

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Aggressive 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.


The 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.


In 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.


Cortical 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.

ABBREVIATIONS CVD = cortical venous drainage; dAVF = dural arteriovenous malformation; NHND = nonhemorrhagic neurological deficit; SRS = stereotactic radiosurgery.

Article Information

Correspondence Bradley A. Gross: University of Pittsburgh, PA.

INCLUDE WHEN CITING Published online March 16, 2018; DOI: 10.3171/2017.10.JNS171802.

Disclosures Dr. Lunsford is a stockholder of Elekta AB and has been a consultant for Insightec.

© AANS, except where prohibited by US copyright law.




Awad IALittle JRAkarawi WPAhl J: Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course. J Neurosurg 72:8398501990


Bulters DOMathad NCulliford DMillar JSparrow OC: The natural history of cranial dural arteriovenous fistulae with cortical venous reflux—the significance of venous ectasia. Neurosurgery 70:3123192012


Chandra RVLeslie-Mazwi TMMehta BPYoo AJRabinov JDPryor JC: Transarterial Onyx embolization of cranial dural arteriovenous fistulas: long-term follow-up. AJNR Am J Neuroradiol 35:179317972014


Chen CJLee CCDing DStarke RMChivukula SYen CP: Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review. J Neurosurg 122:3533622015


Cifarelli CPKaptain GYen CPSchlesinger DSheehan JP: Gamma Knife radiosurgery for dural arteriovenous fistulas. Neurosurgery 67:123012352010


Cognard CGobin YPPierot LBailly ALHoudart ECasasco A: Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 194:6716801995


Djindjian RMerland JJThéron J: Super-Selective Arteriography of the External Carotid Artery. Berlin: Springer1978


Friedman JAPollock BENichols DAGorman DAFoote RLStafford SL: Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses. J Neurosurg 94:8868912001


Gross BAAlbuquerque FCMoon KMcDougall CG: Evolution of treatment and a detailed analysis of occlusion, recurrence, and clinical outcomes in an endovascular library of 260 dural arteriovenous fistulas. J Neurosurg 126:188418932017


Gross BADu R: The natural history of cerebral dural arteriovenous fistulae. Neurosurgery 71:5946032012


Gross BADu R: Surgical treatment of high grade dural arteriovenous fistulae. J Clin Neurosci 20:152715322013


Gross BARopper AEPopp AJDu R: Stereotactic radiosurgery for cerebral dural arteriovenous fistulas. Neurosurg Focus 32(5):E182012


Liu JKDogan AEllegala DBCarlson JNesbit GMBarnwell SL: The role of surgery for high-grade intracranial dural arteriovenous fistulas: importance of obliteration of venous outflow. J Neurosurg 110:9139202009


Pan DHChung WYGuo WYWu HMLiu KDShiau CY: Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse-sigmoid sinus. J Neurosurg 96:8238292002


Park KSKang DHPark SHKim YS: The efficacy of gamma knife radiosurgery alone as a primary treatment for intracranial dural arteriovenous fistulas. Acta Neurochir (Wien) 158:8218282016


Pollock BENichols DAGarrity JAGorman DAStafford SL: Stereotactic radiosurgery and particulate embolization for cavernous sinus dural arteriovenous fistulae. Neurosurgery 45:4594671999


Rangel-Castilla LBarber SMKlucznik RDiaz O: Mid and long term outcomes of dural arteriovenous fistula endovascular management with Onyx. Experience of a single tertiary center. J Neurointerv Surg 6:6076132014


Söderman MEdner GEricson KKarlsson BRähn TUlfarsson E: Gamma knife surgery for dural arteriovenous shunts: 25 years of experience. J Neurosurg 104:8678752006


Söderman MPavic LEdner GHolmin SAndersson T: Natural history of dural arteriovenous shunts. Stroke 39:173517392008


Strom RGBotros JARefai DMoran CJCross DT IIIChicoine MR: Cranial dural arteriovenous fistulae: asymptomatic cortical venous drainage portends less aggressive clinical course. Neurosurgery 64:2412482009


Wu HMPan DHChung WYGuo WYLiu KDShiau CY: Gamma Knife surgery for the management of intracranial dural arteriovenous fistulas. J Neurosurg 105 Suppl:43512006




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