Gamma Knife Radiosurgery For Dural Arteriovenous Fistulas

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.


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