Management Of Dural Arteriovenous Fistulas Research Articles

The Role of Surgery in the Management of Dural Arteriovenous Fistulas

The Role of Surgery in the Management of Dural Arteriovenous Fistulas

UPDATE ON MANAGEMENT OF DURAL ARTERIOVENOUS FISTULAS.

Dural Arteriovenous Fistulas (AVF) represent about 10% of all intracranial vascular lesions. Although they seem benign in nature, the presence of retrograde venous makes them aggressive, with a high risk of complications. Patients may be clinically asymptomatic or experience symptoms ranging from mild to severe hemorrhage, depending on their location. Different treatments are available, but recently, the development of catheter intervention allows most patients to be cured with transcatheter embolization. Stereotactic radiosurgery achieves excellent rates of obliteration for low-grade lesions. In this review, we try to highlight the recent advances in the management of dural AVF.

Embolization of cranial dural arteriovenous fistulas in the liquid embolic era: A Sydney experience

Endovascular management of dural arteriovenous fistulas has become a mainstay of treatment. In particular, modern techniques have allowed greater fistula penetration and likelihood of complete obliteration. However, the efficacy of newer agents has not been quantified outside of predominantly small case reports and case series. Furthermore, the Australian experience with fistula embolization has yet to be reported in the literature. To this aim, we performed a retrospective review of our endovascular management of a large cohort of cranial dural arteriovenous fistulas in the liquid embolic era. This retrospective case series included ninety-six consecutive patients of any Cognard grade, treated between 2005 and 2016. Liquid embolic agents were used exclusively in eighty-three cases. The overall complete obliteration rate was 89.6% with a residual fistula rate of 2%, and complication rate of 8.3%. This Sydney, Australia cohort demonstrates excellent treatment effect and safety outcomes and thus supports the primary treatment of this condition by endovascular means.

Dural Arteriovenous Fistula Manifested as Rapid Progressive Dementia Successfully Treated by Endovascular Embolization Only.

A 43-year-old male presented with daytime sleepiness at work and indifferent behavior like never before. Two weeks prior to hospital admission, he had episodic memory loss with well preserved remote memory. Brain MRI showed a dural arteriovenous fistula (DAVF) in the right lateral transverse sinus with a bilateral thalamic venous infarction. Cerebral angiography confirmed a right transverse sigmoid dural arteriovenous fistula with a feeding artery of the right occipital artery and left posterior meningeal artery. The DAVF was completely eliminated through multiple endovascular interventions. Recently, endovascular treatment has become one of the main therapeutic options to obliterate a fistulous site, which has led to a rapid diagnostic approach and management of DAVFs with high curative rates. We report a rare case of posterior fossa located at a dural arteriovenous fistula that caused rapid progressive dementia and was successfully eliminated through only endovascular treatment.

Flat Detector Computed Tomography-Based “Dual Vessel Fusion” Technique for Diagnosis and Surgical Planning in the Management of Dural Arteriovenous Fistula

To explore the value of flat detector computed tomography-based vessel fusion technique for visualizing and evaluating anatomic structures and hemodynamic features of patients diagnosed with dural arteriovenous fistulas (DAVF). Eleven patients with DAVF were investigated. The 3-dimensional structure of the DAVF fistula point, feeding arteries, and draining veins were reconstructed from separately acquired rotational angiographic images and then displayed as a single image in a fused manner. In the vessel fusion image, the tangled cluster of vessels of the DAVF could be clearly visualized from selected optimal viewing angles in the 3-dimensional space. Each component of the DAVF fistula point with its specific artery feedings and venous drainage could be identified accurately. The vessel fusion technique gave detailed anatomic information that enabled better understanding of the DAVF structure, and facilitated an accurate interventional or surgical planning.

Diagnosis and management of dural arteriovenous fistulas: A 10 years single-center experience

ObjectivesDural arteriovenous fistulas (DAVFs) are a challenging condition in vascular neurosurgery. Disease natural history and its management is still debated. In the present paper we report our center series on DAVFs over a period of 10 years. Our data were compared with relevant literature. Patient and methodsOur series includes 45 cases: 14 cavernous sinus, 11 transverse-sigmoid, 8 patients tentorial, 6 anterior cranial fossa, 5 patients spinal, 1 patient foramen magnum. Results and conclusionsDVAFs distribution, clinical presentation and hemorrhagic risk are discussed. Cavernous sinus DAVFs are the most common site in our series. Other locations in order of frequency are transverse-sigmoid sinus, tentorial, anterior cranial fossa, spinal and foramen magnum. The majority of patients presented with non-aggressive symptoms. 18% presented with intracranial hemorrhage: all the hemorrhages occurred in high-grade DAVFs. For most patients, endovascular treatment, transarterial or transvenous, was the first option. Surgery was performed for the anterior cranial fossa DAVFs and other complex lesions draining mostly transverse-sigmoid sinus and tentorium. In 7% of cases a combination of endovascular+surgical treatment was used. Our series has been carefully analyzed in comparison ‘side by side’ with most relevant literature on DVAFs, focusing particularly on management strategies, therapeutic options and risks related to treatment.

Role of Gamma Knife surgery in the treatment of intracranial dural arteriovenous fistulas

The goal of this study was to assess the efficacy of Gamma Knife surgery (GKS) in the management of dural arteriovenous fistulas (dAVFs). The authors performed a retrospective analysis of a group of 22 patients who underwent GKS for dAVFs at the University of Tokyo Hospital between 1991 and 2009. The patients underwent CT or MR imaging with contrast enhancement every 6 months after GKS; when obliteration of a dAVF was indicated by these images, patients also underwent angiography. Follow-up in these patients ranged from 12 months to 100 months (median 33 months) after GKS. Obliteration of the dAVF was confirmed by neuroimaging in 12 patients (55%). According to a Kaplan-Meier analysis, obliteration rates for the dAVFs were 51% at 3 years and 80% at 5 years. The obliteration rate for lesions without cortical venous drainage (CVD) was 86%, which was significantly higher than the rate for dAVFs with CVD (47%) (p = 0.007). Hemorrhage at presentation (p = 0.03), a target volume less than 1.5 cm(3) (p = 0.009), and Cognard Type III or IV dAVF (p = 0.005) were factors associated with a higher obliteration rate. Among 10 patients whose dAVFs were not obliterated by the initial GKS, 5 patients underwent additional treatment and complete obliteration was achieved in all. Relief of tinnitus was obtained in 5 (83%) of 6 patients with transverse-sigmoid sinus dAVFs, and ophthalmic symptoms improved in 2 (67%) of 3 patients with cavernous sinus dAVFs. No patient experienced interval hemorrhage or radiation-induced complications after treatment. Gamma Knife surgery is a safe and effective treatment for dAVF. It can be a first line of therapy in the multidisciplinary treatment strategy for dAVFs, especially when significant morbidity is anticipated with other therapeutic options. One should be very careful about recommending GKS for patients harboring dAVFs with CVD because of the expected natural history of such a lesion and the possibility of other therapeutic options.

Onyx Pulmonary Artery Embolization After Treatment of a Low-Flow Dural Arteriovenous Fistula: Case Report

Endovascular management of dural arteriovenous fistulas (DAVFs) has become an accepted primary and often definitive therapy. We present the first documented case of Onyx pulmonary embolism after embolization of a low-flow DAVF. A 63-year-old man presented with subarachnoid hemorrhage secondary to a DAVF. Computed tomographic angiography, magnetic resonance imaging, and initial conventional angiogram were negative. A repeat angiogram demonstrated a DAVF, which was cured with Onyx embolization. A routine chest computed tomography after intervention revealed an asymptomatic Onyx embolization cast in a subsegmental pulmonary artery. Endovascular treatment options include transarterial embolization with microcoils, polyvinyl alcohol particles, n-butyl-2cyanoacrylate, and Onyx (ev3 Neurovascular, Irvine, California). Complications associated with the use of Onyx are low but include embolizate pulmonary embolism. Patients often remain asymptomatic, but for symptomatic patients, conservative treatment options usually result in resolution of symptoms.

Indocyanine Green Videoangiography in the Management of Dural Arteriovenous Fistulae

To evaluate the usefulness of indocyanine green (ICG) videoangiography in the operative management of dural arteriovenous fistulae (dAVFs). Intraoperative ICG videoangiography was used as a surgical adjunct in 25 patients with cranial and spinal dural arteriovenous fistulae to identify the fistula and verify its complete obliteration. The findings on ICG videoangiography were compared with intraoperative and/or postoperative imaging. All dural arteriovenous fistulae were clearly identified by intraoperative ICG videoangiography and obliteration was documented in each case. Findings on ICG videoangiography correlated with intraoperative and/or postoperative imaging. ICG videoangiography is a useful adjunct to the surgical management of dural arteriovenous fistulae for localization and confirmation of complete obliteration. The safety and ease of use make it an attractive modality. The surgeon can only evaluate what is visualized under the operating microscope and must therefore fully expose the venous drainage of the fistula to confirm obliteration.

Manejo quirúrgico de las malformaciones arteriovenosas durales craneales: Serie de seis casos

In this article, we describe our experience in surgical management of dural arteriovenous fistulae (dAVF). From August 2001 to February 2006 a total of six patients, were admitted at our hospital, 2 women and 4 men with ages between 40 and 68 years. Four of the six cases were entered through the service of Emergency Service by neurological deficit (in two cases) or decrease in the level of consciousness (in two patients); the remaining two patients were referred by lengthy headache and alterations on neuroimaging studies suggestive of dAVF. All of them showed dAVF in different locations which were treated successfully with surgery after angiographic studies. Although multiple therapeutic options are available, surgery is the treatment of choice in dAVF which shows aggressive clinical course, especially intracranial hemorrhage.

Surgical management of dural arteriovenous fistulas with transosseous arterial feeders involving the jugular bulb

Dural arteriovenous fistulas located in the vicinity of the jugular foramen are complex vascular malformations and belong to the most challenging skull base lesions to treat. The authors comprehensively analyze multiple features in a series of dural arteriovenous fistulas with transosseous arterial feeders involving the jugular bulb. Four patients who underwent surgery via the transcondylar approach to treat dural arteriovenous fistulas around the jugular foramen were retrospectively reviewed. Previously, endovascular treatment was attempted in all patients. The success of the surgical treatment was examined with postoperative angiography. Complete obliteration of the dural arteriovenous fistulas (DAVFs) was achieved in three patients, and significant flow reduction in one individual. All patients had a good postoperative outcome, and only one experienced mild hypoglossal nerve palsy. Despite extensive bone drilling, an occipitocervical fusion was necessary in only one patient with bilateral lesions. The use of an individually tailored transcondylar approach to treat dural arteriovenous fistulas at the region of the jugular foramen is most effective. This approach allows for complete obliteration of the connecting arterial feeders, and removal of bony structures containing pathological vessels.