Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses

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Object. Most dural arteriovenous fistulas (DAVFs) of the transverse and sigmoid sinuses do not have angiographically demonstrated features associated with intracranial hemorrhage and, therefore, may be treated nonsurgically. The authors report their experience using a staged combination of radiosurgery and transarterial embolization for treating DAVFs involving the transverse and sigmoid sinuses.

Methods. Between 1991 and 1998, 25 patients with DAVFs of the transverse and/or sigmoid sinuses were treated using stereotactic radiosurgery; 22 of these patients also underwent transarterial embolization. Two patients were lost to follow-up review. Clinical data, angiographic findings, and follow-up records for the remaining 23 patients were collected prospectively. The mean duration of clinical follow up after radiosurgery was 50 months (range 20–99 months).

The 18 women and five men included in this series had a mean age of 57 years (range 33–79 years). Twenty-two (96%) of 23 patients presented with pulsatile tinnitus as the primary symptom; two patients had experienced an earlier intracerebral hemorrhage (ICH). Cognard classifications of the DAVFs included the following: I in 12 patients (52%), IIa in seven patients (30%), and III in four patients (17%). After treatment, symptoms resolved (20 patients) or improved significantly (two patients) in 96% of patients. One patient was clinically unchanged. No patient sustained an ICH or irradiation-related complication during the follow-up period. Seventeen patients underwent follow-up angiographic studies at a mean of 21 months after radiosurgery (range 11–38 months). Total or near-total obliteration (> 90%) was seen in 11 patients (65%), and more than a 50% reduction in six patients (35%). Two patients experienced recurrent tinnitus and underwent repeated radiosurgery and embolization at 21 and 38 months, respectively, after the first procedure.

Conclusions. A staged combination of radiosurgery and transarterial embolization provides excellent symptom relief and a good angiographically verified cure rate for patients harboring low-risk DAVFs of the transverse and sigmoid sinuses. This combined approach is a safe and effective treatment strategy for patients without angiographically determined risk factors for hemorrhage and for elderly patients with significant comorbidities.

Article Information

Address reprint requests to: Bruce E. Pollock, M.D., Department of Neurological Surgery, Mayo Clinic, East 6B, 200 First Street SW, Rochester, Minnesota 55905.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 17. Left: Anterior ECA angiogram obtained before treatment revealing a large DAVF of the transverse—sigmoid junction, which is supplied by the occipital artery. Right: Anterior ECA angiogram obtained 21 months after radiosurgery demonstrating more than a 50% reduction in the size of the previously noted DAVF, with the appearance of a new adjacent fistula medially along the transverse sinus. This patient initially experienced complete symptom resolution, followed by symptom recurrence months later.

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    Case 7. Left: Lateral ECA angiogram obtained before treatment revealing a DAVF of the transverse and sigmoid sinuses, which is supplied by a markedly dilated occipital artery. Right: Lateral ECA angiogram obtained 13 months after radiosurgery demonstrating complete fistula obliteration and a normalized occipital artery.

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    Case 2. Left: Lateral ECA angiogram obtained before treatment revealing a DAVF of the sigmoid sinus, which is supplied by a dilated, tortuous occipital artery. Right: Lateral ECA angiogram obtained 12 months after radiosurgery demonstrating more than a 90% obliteration of the DAVF, with a faint residual fistula supplied by small branches of the normalized occipital artery. The patient experienced complete symptom resolution and no additional angiographic study was performed.

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