Abstract
This study aims to evaluate a single-center experience with endovascular treatment of cranial dural arterievenous fistulae (CDAVF). The clinical and radiological records of 170 consecutive patients harboring a CDAVF and treated endovascularly in a 16-year period were reviewed. A variety of data related to demographics, features of the lesion, treatment, outcome, and follow-up were analyzed with emphasis to the results and complications. Half of the lesions had cortical venous drainage (CVD) in the initial angiographic investigation, whereas 26 % had exclusively CVD. Sixty-seven percent of our patients presented with benign symptoms and 33 % with aggressive symptoms. In 60.5 % of the patients with benign lesion (without CVD), an anatomic cure in the immediate postinterventional angiogram without complication or permanent morbidity was achieved, whereas 69 % of the patients with aggressive lesions (with CVD) had an anatomic cure in the postinterventional final angiogram with all permanent-morbidity cases belonging to this group. The average of endovascular operation sessions per patient was 1.2. In a mean follow-up period of 2.8 years, the overall complete occlusion rate was 85.5 % (78 % for the benign group and 89.5 % for the aggressive group) and clinical cure and/or improvement rate of 93 %. The operative mortality was zero, and permanent neurologic morbidity was 2.3 %. In 73 % of our cases, N-butyl cyanoacrylate (NBCA) was used as the only or main embolic material. Endovascular embolization is the treatment of choice for CDAVF. High rates of good anatomical and clinical results, associated with very low operative complication rate can be achieved with few embolization sessions. Although mastering of a permanent embolic material is important, the therapeutic strategy should be individulized and not material based.
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Timo Krings, Toronto, Canada
This is one of the largest single-center series on the treatment of dural arteriovenous fistulae that highlights the high success rates and the low complication rates if anatomy is respected and the nature of the disease is understood. One of the major benefits of this article is the long follow-up that allows the reader to deduce that once stable obliteration of the DAVF is obtained, chances of recurrence are very low. The manuscript also demonstrates the goal of treatment in cranial dural arteriovenous fistulae, i.e., the obliteration of the transition between the arterial and venous segment. It is not the type of embolizing agent that will make a difference in complication and cure rate but instead the knowledge of the supply to the cranial nerves and prediction of the existence and location of the so-called “dangerous” EC-IC anastomoses especially at the level of the cavernous sinus that has to be mastered to obtain the results presented in this article. Or, as Pierre Lasjaunias used to phrase it: “Anatomy is the cheapest way to safe.”
Giuseppe Lanzino, Rochester, USA
With better understanding of their angioarchitecture and pathophysiology, continuous refinement of endovascular materials and techniques, most intracranial dural arteriovenous fistulas (DAVFs) can nowadays be effectively treated with very low morbidity and mortality. In their monumental series encompassing 16 years, Baltsavias and Valavanis report their experience with embolization of 170 consecutive patients with intracranial DAVFs. Sixty-seven percent of patients suffered from benign symptoms (usually related to high-flow conditions) such as bruit and conjunctival injection, while the remaining presented with an aggressive clinical picture. Immediate anatomic cure was achieved in 60.5 % of patients with benign symptoms and 69 % of those with aggressive lesions. These rates of complete anatomical obliteration increased to 78 % for the benign group and 89.5 % for the aggressive DAVFs. There was no mortality in this series, and the permanent morbidity rate was very low (in the low single digits). This remarkable experience illustrates what can be achieved today with endovascular techniques in the hands of a recognized master with incredible skills and experience.
The availability of different treatment modalities (which are often complementary) allows the treating physician to individualize treatment based on the clinical and radiological characteristics of the specific patients. Patients with minimally symptomatic fistulas without retrograde cortical venous drainage can be safely managed conservatively, and in several cases, I have observed remarkable spontaneous regression of the fistula, including spontaneous occlusion. Because of this, I believe that some of those cases that have been described to resolve after intermittent carotid compressions might indeed represent just the benign natural history and evolution of some of these lesions independent of the intermittent compression. Patients with disabling symptoms associated with high-flow conditions, in the absence of retrograde cortical venous drainage, are offered at our Institution, transarterial particulate embolization with the idea of “palliate” their symptoms. This approach (using particles greater than 150 μm in the external carotid artery branches) is extremely safe and effective in resolving patients’ symptoms. Often, this strategy of transarterial PVA embolization is combined with gamma knife radiosurgery. Gamma knife is extremely effective in achieving complete obliteration within usually 1 year, especially in the case of transverse/sigmoid sinus and cavernous sinus DAVFs. In patients with aggressive clinical symptoms, we try to achieve a rapid cure. In these cases, coil embolization of the involved venous drainage usually through a transvenous approach remains our treatment of choice particularly for indirect cavernous sinus fistulas. Patients with exclusive retrograde cortical venous drainage are in our hands often effectively treated with transarterial Onyx embolization, especially when a straight feeder such as the posterior branch of the middle meningeal artery is available for embolization. With the availability of these complementary non invasive solutions, it is uncommon nowadays to recur to surgical interruption of the fistula. However, surgery is still a valid option when endovascular techniques are not effective, and patients have presented with aggressive symptoms or have significant retrograde cortical venous drainage.
Karel terBrugge, Toronto, Canada
I have read with great interest the manuscript by Baltsavias and Valavanis regarding their large experience with endovascular management of patients with intracranial dural arteriovenous fistulas (SDAVFs). The team of Professor Valavanis is well known and well accomplished, and their management outcome resulted in an 89.5 % obliteration rate of DAVFs with cortical venous reflux using predominantly glue as the embolic agent of choice. The associated permanent complication rate was 2.3 %. In the so-called benign DAVFs, a cure was confirmed on follow up in 78 % of treated patients and no permanent complications occurred. Publication of this experience is very timely in view of the shift towards the use of ONYX as the embolic material of choice for the endovascular management of this condition, and the current publication will serve as a standard against which other treatment modalities outcomes can be compared. We congratulate the Zurich team on this excellent work. KTB
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Baltsavias, G., Valavanis, A. Endovascular treatment of 170 consecutive cranial dural arteriovenous fistulae: results and complications. Neurosurg Rev 37, 63–71 (2014). https://doi.org/10.1007/s10143-013-0498-2
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DOI: https://doi.org/10.1007/s10143-013-0498-2