Cranial dural arteriovenous fistulae: asymptomatic cortical venous drainage portends less aggressive clinical course.

Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
Neurosurgery (Impact Factor: 2.53). 03/2009; 64(2):241-7; discussion 247-8. DOI:10.1227/01.NEU.0000338066.30665.B2
Source: PubMed

ABSTRACT Cranial dural arteriovenous fistulae (dAVF) with cortical venous drainage (CVD) (Borden Types 2 and 3) are reported to carry a 15% annual risk of intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND). The purpose of this study was to compare the clinical course of Type 2 and 3 dAVFs that present with ICH or NHND with those that do not.
Twenty-eight patients with Type 2 or 3 dAVFs were retrospectively evaluated. CVD was classified as asymptomatic (aCVD) if patients presented incidentally or with pulsatile tinnitus or orbital phenomena. CVD was classified as symptomatic (sCVD) if patients presented with ICH or NHND. Occurrence of new ICH or new or worsening NHND between diagnosis and disconnection of CVD or last follow-up (if not disconnected) was noted. Overall frequency of events was compared using Fisher's exact test. Cumulative, event-free survival was compared using Kaplan-Meier analysis with log-rank testing.
Of 17 patients with aCVD, 1 (5.9%) developed ICH and none experienced NHND or death during the median 31.4-month follow-up period. Of 11 patients with sCVD, 2 (18.2%) developed ICH and 3 (27.3%) experienced new or worsened NHND over the median 9.7-month follow-up period. One of these patients subsequently died. Overall frequency of ICH or NHND was significantly lower in patients with aCVD versus sCVD (P = 0.022). Respective annual event rates were 1.4 versus 19.0%. aCVD patients had significantly higher cumulative event-free survival (P = 0.0016).
Cranial dAVFs with aCVD may have a less aggressive clinical course than those with sCVD.

0 0
  • [show abstract] [hide abstract]
    ABSTRACT: Dural arteriovenous fistulas (dAVFs) are vascular lesions involving direct connections between intracranial dural arteries and venous sinuses. The goal of treatment of these vascular lesions is to alleviate symptoms and prevent future hemorrhage. While endovascular embolization remains the primary method of treatment and obliteration of dAVF recently, stereotactic radiosurgery (SRS) has been used as a treatment modality in select dAVF either alone or in conjunction with endovascular embolization. Considering recent studies examining dAVFs natural history and possible therapeutic interventions, the authors provide a concise review of the literature and discuss the indications, efficacy, and safety of SRS in the management of dAVFs.
    Clinical neurology and neurosurgery 03/2013; · 1.30 Impact Factor
  • [show abstract] [hide abstract]
    ABSTRACT: The aim of this study is to assess the relationship between the venous angioarchitectural features and the clinical course of intracranial dural arteriovenous shunt (DAVS) with cortical venous reflux (CVR). With institutional review board approval, 41 patients (M:F = 24:17; median age, 52 years (range, 1-72 years), median follow-up; 1.5 years; partial treatment, n = 36) with persistent CVR were included. We evaluated the initial presentation and the incidence of annual morbidity (hemorrhage or new/worsened nonhemorrhagic neurological deficit (NHND)) according to the venous angiographic patterns-isolated venous sinus, occlusion of the draining sinus, direct pial venous drainage, pseudophlebitic pattern, venous ectasia, brisk venous drainage, and length of pial vein reflux-on digital subtraction angiography. Cox regression was performed to identify independent factors for clinical course. During 111.9 patient-years of follow-up, the overall annual morbidity rate was 11.6 % (mortality; n = 3, rate; 2.6 %/year). Hemorrhage occurred in five patients (12.2 %, rate; 4.5 %/year) and new/worsened NHND occurred in eight patients (19.5 %, rate; 7.2 %/year). Patients with isolated venous sinus, direct pial venous drainage, and pseudophlebitic pattern were associated with initial aggressive presentation. Venous ectasia was associated with initial hemorrhagic presentation. Brisk venous drainage was associated with initial benign presentation. Patients with isolated venous sinus showed a poor clinical course with a higher annual incidence of hemorrhage or new/worsened NHND (91.2 %/year vs 9.2 %/year; hazard ratio, 6.681; p = 0.027). Venous angioarchitectural features may be predictive of the clinical course of DAVSs. DAVS patients with isolated venous sinus may be especially at high risk for future aggressive clinical course.
    Neuroradiology 06/2013; · 2.70 Impact Factor
  • [show abstract] [hide abstract]
    ABSTRACT: Leptomeningeal venous drainage and symptomatic presentation are known risk factors for cerebral dural arteriovenous fistula (dAVF) hemorrhage. An evaluation of potentially modifiable risk factors such as hypertension and medication usage has not been undertaken to our knowledge. The authors thus reviewed a cohort of 45 consecutive patients with cerebral dAVF with leptomeningeal venous drainage and compared the rate of hemorrhagic presentation for patients with and without a history of hypertension, hyperlipidemia or the usage of certain medications. Logistic regression was performed to determine the statistical significance of associations of each factor with hemorrhagic presentation. On univariate analysis, angiotensin-converting enzyme (ACE)-inhibitors (odds ratio [OR] 0.100, 95% confidence interval [CI] 0-0.764, p=0.024) and statins (OR 0.142, 95% CI 0.025-0.825, p=0.030) were associated with a statistically significant lower rate of hemorrhagic presentation. A trend toward a lower rate of hemorrhagic presentation was seen for patients taking aspirin (OR 0.153, 95% CI 0.016-1.43, p=0.10). These trends continued on multivariate analysis; however they did not meet statistical significance (p>0.05). Beta-blockers, calcium channel blockers, warfarin and selective serotonin reuptake inhibitors did not have a statistically significant association with the rate of hemorrhagic presentation (p>0.05). Although limited by small sample size, these results may suggest a beneficial effect of statins and ACE-inhibitors on the rate of dAVF hemorrhagic presentation, potentially as a result of anti-inflammatory, anti-angiogenic or even venous antithrombotic mechanisms. Despite this study's limitations, we hope it encourages further evaluation of potentially modifiable risk factors for vascular malformation hemorrhage.
    Journal of Clinical Neuroscience 05/2013; · 1.25 Impact Factor