Prognosis and treatment of intracranial dural arteriovenous fistulae: a systematic review and meta-analysis.

Abstract

Dural arteriovenous fistulae can cause intracranial hemorrhage, but influences on this are unclear. We searched Ovid MEDLINE (from 1966), Embase (from 1980), and the Cochrane Library in September 2013 for studies of ≥50 adults with dural arteriovenous fistulae describing death or intracranial hemorrhage. Of 16 studies of retrospective associations between dural arteriovenous fistulae vascular anatomy and prior mode of presentation, fistula location in the cavernous sinus was consistently associated with nonhemorrhagic modes of presentation; in five studies involving 855 patients, fistulae with retrograde leptomeningeal (cortical) venous drainage were associated with prior presentation with intracranial hemorrhage (pooled odds ratio 23·2, 95% CI 13·8 to 39·0; I(2) = 0%). Future intracranial hemorrhage during untreated clinical course was statistically significantly associated with the presence of venous varix in one study and with presentation with intracranial hemorrhage in patients with retrograde leptomeningeal venous drainage in another. In 19 observational studies of treatment of dural arteriovenous fistulae involving 2329 patients, the pooled risk of death was 1·2% (95% CI 0·6 to 1·8, I(2) = 35%), that of nonfatal intracranial haemorrhage was 0·5% (95%CI 0·2 to 0·8, I(2) = 9%), and that of nonfatal cerebral infarction was 0·7% (95% CI 0·3 to 1·4, I(2) = 52%), for a combined risk of 2·5% (95% CI 1·4 to 3·9, I(2) = 69%). Retrograde leptomeningeal venous drainage seems strongly associated with intracranial hemorrhage at presentation of dural arteriovenous fistula, but its association with subsequent intracranial hemorrhage is less clear. Short-term complications of dural arteriovenous fistula treatment affect 2-3% of patients in published reports.