The authors performed a study to evaluate the hemorrhagic rates of cerebral dural arteriovenous fistulas (dAVFs) and the risk factors of hemorrhage following Gamma Knife radiosurgery (GKRS).
Data from a cohort of patients undergoing GKRS for cerebral dAVFs were compiled from the International Radiosurgery Research Foundation. The annual posttreatment hemorrhage rate was calculated as the number of hemorrhages divided by the patient-years at risk. Risk factors for dAVF hemorrhage prior to GKRS and during the latency period after radiosurgery were evaluated in a multivariate analysis.
A total of 147 patients with dAVFs were treated with GKRS. Thirty-six patients (24.5%) presented with hemorrhage. dAVFs that had any cortical venous drainage (CVD) (OR = 3.8, p = 0.003) or convexity or torcula location (OR = 3.3, p = 0.017) were more likely to present with hemorrhage in multivariate analysis. Half of the patients had prior treatment (49.7%). Post-GRKS hemorrhage occurred in 4 patients, with an overall annual risk of 0.84% during the latency period. The annual risks of post-GKRS hemorrhage for Borden type 2–3 dAVFs and Borden type 2–3 hemorrhagic dAVFs were 1.45% and 0.93%, respectively. No hemorrhage occurred after radiological confirmation of obliteration. Independent predictors of hemorrhage following GKRS included nonhemorrhagic neural deficit presentation (HR = 21.6, p = 0.027) and increasing number of past endovascular treatments (HR = 1.81, p = 0.036).
Patients have similar rates of hemorrhage before and after radiosurgery until obliteration is achieved. dAVFs that have any CVD or are located in the convexity or torcula were more likely to present with hemorrhage. Patients presenting with nonhemorrhagic neural deficits and a history of endovascular treatments had higher risks of post-GKRS hemorrhage.
Correspondence David McCarthy: University of Miami Miller School of Medicine, Miami, FL. firstname.lastname@example.org.
INCLUDE WHEN CITING Published online March 15, 2019; DOI: 10.3171/2018.12.JNS182208.
Disclosures Dr. Vargo reports receiving speaking honoraria from Brainlab. Dr. Lunsford reports stock ownership in Elekta and being a consultant for Insightec, DSMB. Dr. Kano reports he has an Elekta Research Grant and is an Elekta AB grant recipient.
Cohen-InbarOStarkeRMPaisanGKanoHHuangPPRodriguez-MercadoR: Early versus late arteriovenous malformation responders after stereotactic radiosurgery: an international multicenter study. J Neurosurg127:503–5112017
Della PepaGMParentePD’ArgentoFPedicelliASturialeCLSabatinoG: Angio-architectural features of high-grade intracranial dural arteriovenous fistulas: correlation with aggressive clinical presentation and hemorrhagic risk. Neurosurgery81:315–3302017
FriedmanJAPollockBENicholsDAGormanDAFooteRLStaffordSL: Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses. J Neurosurg94:886–8912001
LiCWangYLiYJiangCYangXWuZ: Clinical and angioarchitectural risk factors associated with intracranial hemorrhage in dural arteriovenous fistulas: a single-center retrospective study. PLoS One10:e01312352015
ShahMNBotrosJAPilgramTKMoranCJCrossDTIIIChicoineMR: Borden-Shucart Type I dural arteriovenous fistulas: clinical course including risk of conversion to higher-grade fistulas. J Neurosurg117:539–5452012
TonettiDAGrossBAJankowitzBTKanoHMonacoEANiranjanA: Reconsidering an important subclass of high-risk dural arteriovenous fistulas for stereotactic radiosurgery. J Neurosurg[epub ahead of print March 1 2018. DOI: 10.3171/2017.10.JNS171802]
WillinskyRGoyalMterBruggeKMontaneraW: Tortuous, engorged pial veins in intracranial dural arteriovenous fistulas: correlations with presentation, location, and MR findings in 122 patients. AJNR Am J Neuroradiol20:1031–10361999