Gamma Knife surgery for low-flow cavernous sinus dural arteriovenous fistulas

Clinical article

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The purpose of this study was to assess the efficacy of Gamma Knife surgery (GKS) for treating cavernous sinus dural arteriovenous fistulas (CSDAVFs).


Of the 4123 GKSs performed between May 1992 and March 2009, 890 procedures were undertaken to treat vascular lesions. In 24 cases, the vascular lesion that was treated was a dural arteriovenous fistula, and in 6 of these cases, the lesion involved the cavernous sinus. One of these 6 cases was lost to follow-up, leaving the other 5 cases (4 women and 1 man) to comprise the subjects of this study. All 5 patients had more than 1 ocular symptom, such as ptosis, chemosis, proptosis, and extraocular movement palsy. In all patients, CSDAVF was confirmed by conventional angiography. Three patients were treated by GKS alone and 2 patients were treated by GKS combined with transarterial embolization. The median follow-up period after GKS in these 5 cases was 30 months (range 9–59 months).


All patients experienced clinical improvement, and their improvement in ocular symptoms was noticed at a mean of 17.6 weeks after GKS (range 4–24 weeks). Two patients received embolization prior to GKS but did not display improvement in ocular symptoms. An average of 20 weeks (range 12–24 weeks) was needed for complete improvement in clinical symptoms. There were no treatment-related complications during the follow-up period.


Gamma Knife surgery should be considered as a primary, combined, or additional treatment option for CSDAVF in selected cases, such as when the lesion is a low-flow shunt without cortical venous drainage. For those selected cases, GKS alone may suffice as the primary treatment method when combined with close monitoring of ocular symptoms and intraocular pressure.

Abbreviations used in this paper: AVM = arteriovenous malformation; CS = cavernous sinus; CSDAVF = CS dural arteriovenous fistula; DAVF = dural arteriovenous fistula; ECA = external carotid artery; EOM = extraocular muscle; GKS = Gamma Knife surgery; ICA = internal carotid artery; IOP = intraocular pressure; SOV = superior ophthalmic vein.

Article Information

Address correspondence to: Jong Hee Chang, M.D., Ph.D., Department of Neurosurgery, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul, Republic of Korea. email:

© AANS, except where prohibited by US copyright law.



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    Case 4. Conventional angiography before radiosurgery and a snapshot of the dose plan. Upper: Conventional angiograms showing a Barrow Type D CSDAVF. Lower: Dosimetry plan showing that the green line (8 Gy) is sufficiently distant from the optic apparatus.

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    Case 4. Graph showing a change in IOP after GKS. The IOP decreased to within normal range (20 mm Hg) 4 weeks after GKS.

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    Case 4. Computed tomography angiograms (left) and photographs (center and right) obtained before and after GKS. Upper: Pretreatment CT angiogram showing a prominent SOV in the orbit and photographs showing the patient's ptosis, exophthalmos, and chemosis. Lower: Posttreatment CT angiogram obtained 12 weeks after GKS showing that the SOV is no longer engorged and photographs showing that the patient's ocular symptoms have improved.

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    Case 5. Photographs of the patient. Upper: Before treatment, the patient demonstrated right-sided lateral gaze palsy, chemosis, and mild exophthalmos. Lower: Twenty-four weeks after GKS, the patient's symptoms have improved.


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