Gamma knife radiosurgery for dural arteriovenous fistulas: a meta-analysis of treatment strategy and results in four different gamma knife centers

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

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     Treatment options for dural arteriovenous fistulas (DAVFs) have expanded with the application of Gamma knife radiosurgery (GKS). 
     To assess the role of GKS in treatment of DAVFs, we reviewed our entire DAVF experience and compared with three recent published DAVFs GKS treatment series from different centers.
     Between 1993 and 2010, 368 DAVFs underwent GKS in our hospital. In our series, 216 patients were Cavernous-carotid fistulas, 97 patients were transverse-sigmoid fistulas and 55 patients had DAVF in other location. 327 patients (89%) had only Gamma knife treatment and other 41 patients (11%) had combined treatment with embolization or surgery. Seventy-five patients (20%) were diagnosed after sustaining an intracranial hemorrhage. 
     We selected three recent published GKS series from University of Pittsburgh, University of Virginia, and Karolinska University hospital (series at least had 40 patients with more than 3 years follow-up published in recent 5 years) for comparison. We compared patients’ selection, treatment strategy, dose plan, treatment results and complication of four different series and try to find out the common conclusion in current GKS treatment for DAVFs.
     We found more than 95% of patients had neurological symptom improvement during follow-up. Seventy percent of 216 patients with cavernous-carotid fistulas and 59% of patients with non cavernous-carotid fistulas had obliteration confirmed by imaging.
     This was a retrospective study.
     GKS is a safe and effective treatment modality for intracranial DAVFs. For low risk DAVFs with benign clinical presentation, GKS can serve as a primary treatment. Symptom improvement rate and image proved obliteration rate can be achieved in more than 70% to 90% within 2 years with little adverse events. 
     For high risk DAVFs with extensive retrograde cortical venous drainage, hemorrhage or severe venous hypertension, treatment combined with embolization or surgery is suggested.


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