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

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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.


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.


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.


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.

Article Information

Correspondence David J. McCarthy: University of Miami Miller School of Medicine, Miami, FL. djm77@med.miami.edu.

INCLUDE WHEN CITING Published online January 4, 2019; DOI: 10.3171/2018.8.JNS181467.

Disclosures Dr. Vargo reports receiving a speaking honorarium from BrainLAB. Dr. Hideyuki Kano reports receiving an Elekta AB research grant. Dr. Grills reports stock ownership in Greater Michigan Gamma Knife and is on the executive board of directors for Greater Michigan Gamma Knife. Dr. Lunsford reports direct stock ownership in Elekta AB; he is a consultant for Insightec.

© AANS, except where prohibited by US copyright law.



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    Kaplan-Meier plot of overall dAVF obliteration over time. The postradiosurgery actuarial rates of obliteration at 3, 5, 7, and 10 years were 41.3%, 61.1%, 70.1%, and 82.0%, respectively. Values at the bottom of the figure correspond to the number of patients available for each follow-up interval (114 for 2 years, 81 for 4 years, and so on).

  • View in gallery

    Kaplan-Meier plot of dAVF obliterations over time stratified by predictive factor. The postradiosurgery Kaplan-Meier plots of obliteration stratified by sex (A), cavernous carotid fistula location (CCF) and noncavernous location (No-CCF) (B), and the presence of venous ectasia (VE) and the absence of venous ectasia (No-VE) (C). Values at the bottom of each panel correspond to the number of male and female patients (A), the number of patients with noncavernous dAVFs (NC-dAVFs) and C-dAVFs (B), and the number of patients without venous ectasia and with venous ectasia (C) available for each follow-up interval (66 males and 48 females at 2 months [A], 95 NC-dAVFs and 19 C-dAVFs at 2 months [B], and 91 patients without venous ectasia and 23 patients with venous ectasia at 2 months [C], and so on).



Altman DG: Practical Statistics for Medical Research. Boca Raton, FL: CRC Press1990


Borden JAWu JKShucart WA: A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg 82:1661791995


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


Chaichana KLCoon ALTamargo RJHuang J: Dural arteriovenous fistulas: epidemiology and clinical presentation. Neurosurg Clin N Am 23:7132012


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


Cohen-Inbar OStarke RMKano HBowden GHuang PRodriguez-Mercado R: Stereotactic radiosurgery for cerebellar arteriovenous malformations: an international multicenter study. J Neurosurg 127:5125212017


Cohen-Inbar OStarke RMPaisan GKano HHuang PPRodriguez-Mercado R: Early versus late arteriovenous malformation responders after stereotactic radiosurgery: an international multicenter study. J Neurosurg 127:5035112017


Elhammady MSAmbekar SHeros RC: Epidemiology, clinical presentation, diagnostic evaluation, and prognosis of cerebral dural arteriovenous fistulas. Handb Clin Neurol 143:991052017


Fine JPGray RJ: A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 94:4965091999


Gomez JAmin AGGregg LGailloud P: Classification schemes of cranial dural arteriovenous fistulas. Neurosurg Clin N Am 23:55622012


Gray RJ: A class of K-sample tests for comparing the cumulative incidence of a competing risk. Ann Stat 16:114111541988


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


Hanakita SKoga TShin MShojima MIgaki HSaito N: Role of Gamma Knife surgery in the treatment of intracranial dural arteriovenous fistulas. J Neurosurg 117 Suppl:1581632012


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


Patibandla MRDing DKano HStarke RMLee JYKMathieu D: Effect of treatment period on outcomes after stereotactic radiosurgery for brain arteriovenous malformations: an international multicenter study. J Neurosurg [epub ahead of print February 2 2018. DOI: 10.3171/2017.8.JNS171336]


Reynolds MRLanzino GZipfel GJ: Intracranial dural arteriovenous fistulae. Stroke 48:142414312017


Sheehan JPStarke RMKano HBarnett GHMathieu DChiang V: Gamma Knife radiosurgery for posterior fossa meningiomas: a multicenter study. J Neurosurg 122:147914892015


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


Starke RMKano HDing DLee JYMathieu DWhitesell J: Stereotactic radiosurgery for cerebral arteriovenous malformations: evaluation of long-term outcomes in a multicenter cohort. J Neurosurg 126:36442017


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


Suh DCLee JHKim SJChung SJChoi CGKim HJ: New concept in cavernous sinus dural arteriovenous fistula: correlation with presenting symptom and venous drainage patterns. Stroke 36:1111392005


Tonetti DAGross BAJankowitz BTKano HMonaco EA IIINiranjan A: Reconsidering an important subclass of high-risk dural arteriovenous fistulas for stereotactic radiosurgery. J Neurosurg [epub ahead of print March 16 2018. DOI: 10.3171/2017.10.JNS171802]


van Dijk JMterBrugge KGWillinsky RAWallace MC: Clinical course of cranial dural arteriovenous fistulas with long-term persistent cortical venous reflux. Stroke 33:123312362002


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


Yang HCKano HKondziolka DNiranjan AFlickinger JCHorowitz MB: Stereotactic radiosurgery with or without embolization for intracranial dural arteriovenous fistulas. Neurosurgery 67:127612852010


Yen CPDing DCheng CHStarke RMShaffrey MSheehan J: Gamma Knife surgery for incidental cerebral arteriovenous malformations. J Neurosurg 121:101510212014


Zipfel GJShah MNRefai DDacey RG JrDerdeyn CP: Cranial dural arteriovenous fistulas: modification of angiographic classification scales based on new natural history data. Neurosurg Focus 26(5):E142009




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