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. 2023 Nov 24;140(5):1389-1398.
doi: 10.3171/2023.9.JNS231474. Print 2024 May 1.

Stereotactic radiosurgery for noncavernous sinus dural arteriovenous fistulas: treatment outcomes and their predictors

Junhyung Kim  1 , Seung Woo Hong  2 , Hyun Ho Jung  2 , Yong Bae Kim  3 , Joonho Chung  1 , Won Seok Chang  2 , Keun Young Park  3
Affiliations

Stereotactic radiosurgery for noncavernous sinus dural arteriovenous fistulas: treatment outcomes and their predictors

Junhyung Kim et al. J Neurosurg. .

Abstract

Objective: Stereotactic radiosurgery (SRS) has emerged as a safe and effective treatment modality for dural arteriovenous fistulas (dAVFs), particularly cavernous sinus (CS) dAVFs. However, the long-term outcomes of non-CS dAVFs are not well known. This study aimed to evaluate the efficacy and safety of SRS for non-CS dAVFs and to investigate the risk factors for incomplete obliteration.

Methods: Between 2007 and 2020, 65 non-CS dAVFs in 63 patients were treated using SRS at a single institution. Demographic characteristics, initial clinical presentations, clinical outcomes, and radiological findings were retrospectively reviewed. The procedure-related complications were assessed. Radiological outcomes were evaluated as complete obliteration, incomplete obliteration, and angiographic worsening, whereas clinical outcomes were evaluated for symptom recovery.

Results: At a median follow-up of 17 months, the overall complete obliteration rate was 63.1%, and the cumulative obliteration rates were 24.6%, 60.0%, 70.0%, and 74.3% at 12, 24, 36, and 48 months, respectively. Six patients underwent retreatment due to angiographic worsening; in 5 of these patients, recruitment of arterial feeders was newly observed in the adjacent sinus, which was not treated in the initial SRS. In the multivariate analysis, high-flow shunt and venous ectasia were associated with incomplete obliteration. No adverse events occurred after SRS.

Conclusions: SRS for non-CS dAVFs is safe, and its efficacy is highly variable according to location. High-flow shunts may indicate greater radioresistance. In the retreated cases, new fistulas tended to be accompanied by sinus steno-occlusion and formed in the adjacent sinus segments.

Keywords: dural arteriovenous fistula; endovascular neurosurgery; noncavernous sinus; stereotactic radiosurgery; vascular disorders.

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Conflict of interest statement

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Figures

FIG. 1.
FIG. 1.
A 66-year-old man presented with visual disturbance and was diagnosed with an SSS dAVF (Cognard type II a+b). A–C: Images obtained before SRS. Anteroposterior (A) and lateral (B) views of a left external carotid angiogram show SSS dAVF with cortical venous reflux (panel A, arrowhead). Black arrows (panel B) indicate anterograde flow via a patent SSS. SRS dose planning MR image (C). The patient visited the outpatient clinic 25 months after SRS, reporting a headache. D–F: Anteroposterior (D) and lateral (E) views of a left external carotid angiogram reveal increased cortical venous reflux to the right cerebral hemisphere due to the remaining shunt and occluded posterior segment of the SSS (arrowheads). MR image (F) shows hemorrhage in the right temporal lobe. Figure is available in color online only.
FIG. 2.
FIG. 2.
Kaplan-Meier curves for symptomatic recovery and fistula obliteration. A: Complete symptom recovery. B: Obliteration rate for the entire cohort. C: Obliteration rates according to location. D: No CVD versus CVD. E: No venous ectasia versus venous ectasia. F: Low-flow shunt versus high-flow shunt. Figure is available in color online only.
FIG. 3.
FIG. 3.
A 72-year-old woman with a TS-SS dAVF was treated for intractable pulsatile tinnitus (Cognard type II a). A–C: Images obtained before SRS). Anteroposterior (A) and lateral (B) views of a left external carotid angiogram show dAVF causing retrograde sinus drainage. In the anteroposterior view of a right external carotid angiogram (C), feeders from the right occipital artery that form fistulas (arrow) in the proximal left TS are suspected. After SRS, tinnitus disappeared for a while but recurred 16 months after the treatment. D–F: Images obtained after angiographic worsening. Anteroposterior (D) and lateral (E) views of a left external carotid angiogram reveal reduced but residual fistulous flow in the left TS-SS. A right external carotid angiogram (F) demonstrates prominent shunts near the torcular herophili (black arrows, panels D and F). Note that the left proximal TS segment has occluded (black arrowhead, panel D).
See this image and copyright information in PMC

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