Gamma Knife Radiosurgery for dural Arterious venous Fistula -the Vienna experience

Keywords: arteriovenous fistula, radiosurgery, gamma knife, outcome, dural arteriovenous fistula

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     Treatment strategies of dural arterio-venous fistula (dAVF) are diverse including embolisation, surgery, stereotactic radiosurgery and their combination. Spontaneous cure or regression of symptoms are reported but a therapeutic approach is warranted in patients presenting with retrograde cortical venous drainage, hemorrhage or aggressive neurological course. 
     The aim of our study is to present GKN as a safe treatment possibility for dAVF.
     32 patients underwent 40 GKN procedures.
     In a retrospective study we analysed patients presenting with dAVF and treated with Gamma Knife radiosurgery (GKN) in our department between 2001 and 2011.  Patients presented different dAVF location most of them cavernous sinus (n=11) and transverse sinus (n=7). The mean age of patients was 60,3 years (14,7 years SD). Detailed clinical chart review was performed for all patients.The current clinical status of the patients was assessed via a neurological examination, resulting in a mean follow up time of 3,3 years (2,2 years SD). The patient’s outcome was rated according to their residual symptoms. Descriptive statistical analysis included mean values and standard deviation (SD).
     All patients presented with a broad spectrum of symptoms. In detail intracranial haemorrhage (5), ciliary injection (n=8), exophthalmia (n=9), chemosis (n=8), diplopia (n=6), headache (n=8), visual symptoms (n=7), tinnitus (n=7), elevated intraocular pressure (n=6) vertigo (n=2), ataxia (n=2), dysaesthesia (n=4). 16 patients underwent endovascular embolisation before and one after GKN, in six patients embolisation was tried. GKN was performed with 4, 8, 14, and 18mm collimators, respectively. The irradiated mean volume was 3,3 ccm (5,3 ccm SD). The mean prescription radiation dose was 19,1 Gy (1,7 Gy SD) and the central 37,5 Gy (6,6 Gy SD). In 6 patients a second in one a third GKN treatment was necessary. At the time of follow-up, neuroradiological imaging or clinical symptoms were improved substantially in 26% and disappeared completely in 73 % of patients.
     This was a retrospective study.
     GKN is an effective treatment for dAVF in patients with a low risk of complications.
     In our series no further haemorrhage occurred, intraocular pressure normalised rapidly.


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