Intervention for unruptured high-grade intracranial dural arteriovenous fistulas: a multicenter study

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

The risk-to-benefit profile of treating an unruptured high-grade dural arteriovenous fistula (dAVF) is not clearly defined. The aim of this multicenter retrospective cohort study was to compare the outcomes of different interventions with observation for unruptured high-grade dAVFs.

METHODS

The authors retrospectively reviewed dAVF patients from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with unruptured high-grade (Borden type II or III) dAVFs were included and categorized into four groups (observation, embolization, surgery, and stereotactic radiosurgery [SRS]) based on the initial management. The primary outcome was defined as the modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were good outcome (mRS scores 0–2) at final follow-up, symptomatic improvement, all-cause mortality, and dAVF obliteration. The outcomes of each intervention group were compared against those of the observation group as a reference, with adjustment for differences in baseline characteristics.

RESULTS

The study included 415 dAVF patients, accounting for 29, 324, 43, and 19 in the observation, embolization, surgery, and SRS groups, respectively. The mean radiological and clinical follow-up durations were 21 and 25 months, respectively. Functional outcomes were similar for embolization, surgery, and SRS compared with observation. With observation as a reference, obliteration rates were higher after embolization (adjusted OR [aOR] 7.147, p = 0.010) and surgery (aOR 33.803, p < 0.001) and all-cause mortality was lower after embolization (imputed, aOR 0.171, p = 0.040). Hemorrhage rates per 1000 patient-years were 101 for observation versus 9, 22, and 0 for embolization (p = 0.022), surgery (p = 0.245), and SRS (p = 0.077), respectively. Nonhemorrhagic neurological deficit rates were similar between each intervention group versus observation.

CONCLUSIONS

Embolization and surgery for unruptured high-grade dAVFs afforded a greater likelihood of obliteration than did observation. Embolization also reduced the risk of death and dAVF-associated hemorrhage compared with conservative management over a modest follow-up period. These findings support embolization as the first-line treatment of choice for appropriately selected unruptured Borden type II and III dAVFs.

ABBREVIATIONS

aOR = adjusted OR; CONDOR = Consortium for Dural Arteriovenous Fistula Outcomes Research; CVD = cortical venous drainage; dAVF = dural arteriovenous fistula; DSA = digital subtraction angiography; mRS = modified Rankin Scale; NHND = nonhemorrhagic neurological deficit; SRS = stereotactic radiosurgery.

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