Recurrence after cure in cranial dural arteriovenous fistulas: a collaborative effort by the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR)

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  • 1 Departments of Neurological Surgery,
  • | 2 Radiology, and
  • | 3 Mechanical Engineering, and
  • | 4 Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington;
  • | 5 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia;
  • | 6 Department of Neurological Surgery, University of Pittsburgh, Pennsylvania;
  • | 7 Department of Neurosurgery, University of Florida, Gainesville, Florida;
  • | 8 Departments of Neurosurgery and
  • | 9 Radiology, Mayo Clinic, Rochester, Minnesota;
  • | 10 Department of Neurological Surgery, University of Miami, Florida;
  • | 11 Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands;
  • | 12 Department of Neurosurgery, University of Southampton, United Kingdom;
  • | 13 Department of Neurosurgery, Tokushima University, Tokushima, Japan;
  • | 14 Department of Neurosurgery, University of Illinois at Chicago, Illinois;
  • | 15 Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa;
  • | 16 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 17 Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts; and
  • | 18 Departments of Neurological Surgery,
  • | 19 Radiology, and
  • | 20 Neurology, Washington University School of Medicine, St. Louis, Missouri
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OBJECTIVE

Cranial dural arteriovenous fistulas (dAVFs) are often treated with endovascular therapy, but occasionally a multimodality approach including surgery and/or radiosurgery is utilized. Recurrence after an initial angiographic cure has been reported, with estimated rates ranging from 2% to 14.3%, but few risk factors have been identified. The objective of this study was to identify risk factors associated with recurrence of dAVF after putative cure.

METHODS

The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) data were retrospectively reviewed. All patients with angiographic cure after treatment and subsequent angiographic follow-up were included. The primary outcome was recurrence, with risk factor analysis. Secondary outcomes included clinical outcomes, morbidity, and mortality associated with recurrence. Risk factor analysis was performed comparing the group of patients who experienced recurrence with those with durable cure (regardless of multiple recurrences). Time-to-event analysis was performed using all collective recurrence events (multiple per patients in some cases).

RESULTS

Of the 1077 patients included in the primary CONDOR data set, 457 met inclusion criteria. A total of 32 patients (7%) experienced 34 events of recurrence at a mean of 368.7 days (median 192 days). The recurrence rate was 4.5% overall. Kaplan-Meier analysis predicted long-term recurrence rates approaching 11% at 3 years. Grade III dAVFs treated with endovascular therapy were statistically significantly more likely to experience recurrence than those treated surgically (13.3% vs 0%, p = 0.0001). Tentorial location, cortical venous drainage, and deep cerebral venous drainage were all risk factors for recurrence. Endovascular intervention and radiosurgery were associated with recurrence. Six recurrences were symptomatic, including 2 with hemorrhage, 3 with nonhemorrhagic neurological deficit, and 1 with progressive flow-related symptoms (decreased vision).

CONCLUSIONS

Recurrence of dAVFs after putative cure can occur after endovascular treatment. Risk factors include tentorial location, cortical venous drainage, and deep cerebral drainage. Multimodality therapy can be used to achieve cure after recurrence. A delayed long-term angiographic evaluation (at least 1 year from cure) may be warranted, especially in cases with risk factors for recurrence.

ABBREVIATIONS

CCF = carotid-cavernous fistula; CONDOR = Consortium for Dural Arteriovenous Fistula Outcomes Research; CVD = cortical venous drainage; dAVF = dural arteriovenous fistula; NHND = nonhemorrhagic neurological deficit; mRS = modified Rankin Scale.

Supplementary Materials

    • Supplemental Figures 1-3 (PDF 978 KB)

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