The role of gamma knife in treatment of dural arterio-venous fistula.

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

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     Dural arteriovenous fistulas (dAVFs) pose management challenges.
     Our purpose was to assess the role of SRS in the management of dAVFs, outcomes of treatment including SRS for patients with this disease were evaluated.
     Twenty-two patients underwent SRS for dAVFs during the study period. One patient was lost to follow-up evaluation. Twenty-one patients were followed over 12 months after treatment with radiological investigations.
     Records for patients with dAVFs were retrieved from a radiosurgical database between 1990 and 2010 at the University of Tokyo Hospital.Outcomes that include the rates of obliteration and adverse events were retrospectively analyzed in association with location of fistulas, symptoms at onset, and preceding treatment.
     In total, the median follow-up period after SRS was 33 months (range, 12-100 months). Eight patients (36%) presented with intracranial haemorrhage before SRS. Twelve patients (54%) were treated by SRS alone. Eight patients with dAVFs accompanied by corticovenous drainage were treated by SRS in combination with endovascular treatment. Two patients were treated by craniotomy and SRS, and other two patients underwent multimodal treatment in combination of endovascular approach, craniotomy, and SRS. Actuarial obliteration rate at 4 years after SRS was 73% and there was no patient who experienced haemorrhage and radiation-induced complication after treatment. The obliteration rates after treatment were not significantly different between SRS alone group and multimodal group (p = 0.745). Relief of tinnitus was achieved in four (80%) of five patients with transverse-sigmoid dAVFs, and ophthalmic symptoms improved in two (67%) of three patients with cavernous sinus dAVFs.
     This was a retrospective series.
     Treatment including SRS effectively obliterated dAVFs and prevented haemorrhage without severe adverse events. 
     Proper combination with other modalities such as endovascular approach or craniotomy would be effective treatment of choice for patients with aggressive dAVFs.


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