Evaluation of stereotactic radiosurgery for cerebral dural arteriovenous fistulas in a multicenter international consortium

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  • 1 Department of Neurological Surgery, University of Miami, Florida;
  • | 2 Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia;
  • | 3 Department of Neurological Surgery, University of Pittsburgh;
  • | 4 Department of Neurological Surgery, University of Pennsylvania, Philadelphia, Pennsylvania;
  • | 5 Department of Neurological Surgery, University of Sherbrooke, Quebec;
  • | 6 Department of Neurological Surgery, University of Manitoba, Winnipeg, Canada;
  • | 7 Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan;
  • | 8 Departments of Neurological Surgery and
  • | 9 Radiation Oncology, West Virginia University, Morgantown, West Virginia;
  • | 10 Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic; and
  • | 11 Department of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
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OBJECTIVE

In this multicenter study, the authors reviewed the results obtained in patients who underwent Gamma Knife radiosurgery (GKRS) for dural arteriovenous fistulas (dAVFs) and determined predictors of outcome.

METHODS

Data from a cohort of 114 patients who underwent GKRS for cerebral dAVFs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as dAVF obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and dAVF characteristics were assessed to determine predictors of outcome in a multivariate logistic regression analysis; dAVF-free obliteration was calculated in a competing-risk survival analysis; and Youden indices were used to determine optimal radiosurgical dose.

RESULTS

A mean margin dose of 21.8 Gy was delivered. The mean follow-up duration was 4 years (range 0.5–18 years). The overall obliteration rate was 68.4%. The postradiosurgery actuarial rates of obliteration at 3, 5, 7, and 10 years were 41.3%, 61.1%, 70.1%, and 82.0%, respectively. Post-GRKS hemorrhage occurred in 4 patients (annual risk of 0.9%). Radiation-induced imaging changes occurred in 10.4% of patients; 5.2% were symptomatic, and 3.5% had permanent deficits. Favorable outcome was achieved in 63.2% of patients. Patients with middle fossa and tentorial dAVFs (OR 2.4, p = 0.048) and those receiving a margin dose greater than 23 Gy (OR 2.6, p = 0.030) were less likely to achieve a favorable outcome. Commonly used grading scales (e.g., Borden and Cognard) were not predictive of outcome. Female sex (OR 1.7, p = 0.03), absent venous ectasia (OR 3.4, p < 0.001), and cavernous carotid location (OR 2.1, p = 0.019) were predictors of GKRS-induced dAVF obliteration.

CONCLUSIONS

GKRS for cerebral dAVFs achieved obliteration and avoided permanent complications in the majority of patients. Those with cavernous carotid location and no venous ectasia were more likely to have fistula obliteration following radiosurgery. Commonly used grading scales were not reliable predictors of outcome following radiosurgery.

ABBREVIATIONS

C-dAVF = cavernous dAVF; CVD = cortical venous drainage; dAVF = dural arteriovenous fistula; GKRS = Gamma Knife radiosurgery; ICH = intracerebral hemorrhage; RIC = radiation-induced complication; SAH = subarachnoid hemorrhage.

Figure from Minchev et al. (pp 150–158).

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