Gamma Knife Radiosurgery For Dural Arteriovenous Fistulas

Jason P. Sheehan, PhD1, Chris Cifarelli2, Chun Po Yen2, George Kaptain2, David Schlesinger3

1Department of Neurosurgery, University of Virginia 2University of Virginia, Charlottesville, USA 3Charlottesville, United States

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

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     The current management of intracranial dural arteriovenous fistulas (dAVFs) incorporates a multimodal approach involving microneurosurgery, endovascular embolization, as well as radiosurgery.
      This study explores the role of a Gamma Knife radiosurgery (GKRS) for dAVFs.
     The series includes 55 patients with a diagnosed dAVF having undergone Gamma Knife radiosurgery at the University of Virginia Medical Center between 1989 and 2005 with clinical follow-up through 2008.
     A review of medical records was used to obtain clinical history, demographic data, as well as dosimetry. Radiographic records provided location and anatomy of the fistulous malformations. Follow-up angiography was performed at a two to three year interval after treatment with cure defined as complete obliteration of flow through the lesion. Additional follow-up related to clinical symptomatology and quality of life was obtained from direct patient and primary care physician questionnaires received up to nineteen years after initial treatment.
     Fifty-five patients underwent GKRS for dAVF during the study period. Complete medical records were available for all patients, with twenty patients (36%) presenting with intracranial hemorrhage before GKRS. Gamma Knife radiosurgery was preceded by craniotomy for microneurosurgical ablation in eleven patients (20%) or endovascular embolization in thirty-six patients (65%). Follow-up angiography was performed on forty-six patients (83%) with a documented obliteration achieved in thirty of these patients (65%). Patients lost to follow-up were classified as failures of treatment, thus adjusting the range of efficacy from 65% to 54%. Three patients (5%) suffered from a post-treatment hemorrhage during the follow-up period, but no new permanent neurological deficits resulted from these events.
     This was a retrospective study.
     Gamma Knife radiosurgery is an effective adjunct therapy for dAVFs with persistence of flow following open neurosurgical resection or endovascular treatment while still maintaining a role in non-aggressive dAVFs not amenable to either surgery or embolization.
     Methods to improve obliteration rates further will be of value.


Project Roles:

J. Sheehan (), C. Cifarelli (), C. Yen (), G. Kaptain (), D. Schlesinger ()