Article

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 Bookmarks
 · 
94 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Vascular malformations of the brain are often found in the workup of intracranial hemorrhage, seizures, focal neurological deficits, or headaches. Although CT-angiography may reveal an underlying arteriovenous malformation (AVM) or arteriovenous fistula (AVF), other vascular malformations are not easily evaluated on CT and are better seen on magnetic resonance imaging. For the evaluation of AVMs and AVFs, formal digital subtraction angiography remains the gold standard. In the case of AVMs, AVFs, or cavernous malformations (CMs), the lesion may serve as the etiologic source of the symptoms and thus warrant treatment. When feasible, microsurgical resection is the optimal treatment option for AVMs and CMs. Endovascular embolization may serve as a crucial adjunct to microsurgery in the treatment of AVMs. Depending on their vascular anatomy, AVFs may be treated by either endovascular embolization or microsurgery. For inoperable AVMs and dural AVFs necessitating treatment, stereotactic radiosurgery (SRS) may serve as a viable treatment alternative. Capillary telangiectasias and developmental venous anomalies (DVAs) are often incidental findings; they may be found in association with CMs but are not generally considered targets for treatment. Herein, we review diagnostic methods, natural history, and treatment options for these cerebral vascular malformations.
    Current Treatment Options in Neurology 01/2014; 16(1):279. · 1.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Endovascular embolization is the primary therapeutic modality for intracranial dural arteriovenous fistulae. Based on access route, endovascular treatment can be schematically divided into transarterial, transvenous, combined, and direct/percutaneous approaches. Choice of access route and technique depends primarily on dural arteriovenous fistulae angioarchitecture, pattern of venous drainage, clinical presentation, and location. Individualized endovascular approaches result in a high degree of cure with a reasonably low complication rate.
    Neurosurgery Clinics of North America 07/2014; · 1.90 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Dural arteriovenous fistulae can cause intracranial hemorrhage, but influences on this are unclear.Summary of reviewWe 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; I2 = 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, I2 = 35%), that of nonfatal intracranial haemorrhage was 0·5% (95%CI 0·2 to 0·8, I2 = 9%), and that of nonfatal cerebral infarction was 0·7% (95% CI 0·3 to 1·4, I2 = 52%), for a combined risk of 2·5% (95% CI 1·4 to 3·9, I2 = 69%).Conclusions 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.
    International Journal of Stroke 08/2014; · 4.03 Impact Factor