Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas

How I do it: exoscopic disconnection of anterior fossa dural arteriovenous fistulae

BACKGROUND

Brain Dural Arteriovenous Fistulae (DAVF) are acquired abnormal connections between dural arteries and cerebral veins or venous sinuses. Disconnection of the pathological shunt is recommended for high-grade fistulae and cases with intolerable symptoms or previous bleedings. Surgical disconnection remains the preferred method for anterior fossa DAVF.

METHOD

Microsurgical disconnection of anterior fossa DAVF is performed with the assistance of a robotic exoscope. Intraoperative aniography is implemented to confirm the exclusion of DAVF.

CONCLUSION

The exoscope provides excellent lighting and magnification in challenging surgical fields improving surgeon's ergonomics and enabling tailored, minimally invasive approaches without compromising procedural safety or effectiveness.

Transarterial embolization of anterior cranial fossa dural arteriovenous fistulas as a first-line approach: A retrospective single-center study

BACKGROUND

Anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) present unique treatment challenges due to their complex angioarchitecture and high risk of hemorrhage. Recent advancements in endovascular techniques have highlighted the potential of transarterial embolization in managing these fistulas.

OBJECTIVE

The purpose of this study is to evaluate the clinical and angiographic outcomes of transarterial embolization (TAE) as a first-line treatment for ACF DAVFs over a twenty-year period.

METHODS

From March 200 to September 2021, a total of 54 patients harboring ACF DAVFs underwent TAE as a first-line approach at our institution. The clinical presentation, angiographic features, procedure-related complications, clinical outcomes, and angiographic results were analyzed retrospectively.

RESULTS

Among 54 ACF DAVF treated, there were 48 males and 6 females, with a mean age of 52.5 (52.5 ± 13.0) years. Intracranial hemorrhage (51.9%, 28/54) was the most common symptom. A total of 57 embolization attempts were performed. 85.2% (46/54) achieved complete angiographic occlusion immediately post-TAE. Complications occurred in 3.7% (2/54) of patients. 97.6% (41/42) experienced symptom improvement or stabilization during clinical follow-up. Radiological follow-up showed that 85.0% (34/40) maintained complete fistula occlusion. Angiographic recurrence occurred in one (2.5%, 1/40,) patient without any symptoms.

CONCLUSIONS

TAE for ACF DAVFs demonstrates a high rate of complete occlusion with an acceptable safety profile. Further comparative studies with other treatment approaches are recommended to validate these findings.

Microsurgical Treatment of Intracranial Dural Arteriovenous Fistulas: A Collaborative Investigation From the Multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research

BACKGROUND AND OBJECTIVES

First-line therapy for most intracranial dural arteriovenous fistulas (dAVFs) is endovascular embolization, but some require microsurgical ligation due to limited endovascular accessibility, anticipated lower cure rates, or unacceptable risk profiles. We investigated the most common surgically treated dAVF locations and the approaches and outcomes of each.

METHODS

The Consortium for Dural Arteriovenous Fistula Outcomes Research database was retrospectively reviewed. Patients who underwent dAVF microsurgical ligation were included. Patient demographics, angiographic information, surgical details, and postoperative outcomes were collected. The 5 most common surgically treated dAVF locations were analyzed about used surgical approaches and postoperative outcomes. Univariate analyses were performed with statistical significance set at a threshold of P < .05.

RESULTS

In total, 248 patients in the Consortium for Dural Arteriovenous Fistula Outcomes Research database met inclusion criteria. The 5 most common surgically treated dAVF locations were tentorial, anterior cranial fossa (ACF), transverse-sigmoid sinus (TSS), convexity/superior sagittal sinus (SSS), and torcular. Most tentorial dAVFs were approached using a suboccipital, lateral supracerebellar infratentorial approach (39.3%); extended retrosigmoid approach (ERS) (25%); or posterior subtemporal approach (19.6%). All ACF dAVFs used a subfrontal approach; 5.3% also included an anterior interhemispheric approach. Most TSS dAVFs were ligated via ERS (31.3%) or subtemporal (31.3%) approaches. All convexity/SSS dAVFs used an interhemispheric approach. All torcular dAVFs used the suboccipital, lateral supracerebellar infratentorial approach, with 10.5% undergoing simultaneous ERS craniotomy. Angiographic occlusion rates after microsurgery were 85.5%, 100%, 75.8%, 79.2%, and 73.7% for tentorial, ACF, TSS, convexity/SSS, and torcular dAVFs, respectively (P = .02); the permanent neurological complication rates were 1.8%, 2.6%, 9.1%, 0%, and 0% (P = .31). There were no statistically significant differences in development of complications (P = .08) or Modified Rankin Scale at the last follow-up (P = .11) by fistula location.

CONCLUSION

Although endovascular embolization is the first-line treatment for most intracranial dAVFs, surgical ligation is an important alternative. ACF and tentorial fistulas particularly demonstrate high rates of postoperative obliteration.

Feasibility, safety, and efficacy of endovascular treatment of anterior cranial fossa dural arteriovenous fistulas: a systematic review and meta-analysis with a subanalysis for Onyx

Dural Arteriovenous Fistulas (dAVFs) of the anterior cranial fossa (ACF) are uncommon but carry a high risk of hemorrhage and pose substantial treatment challenges. Recent advancements in endovascular treatment (EVT), including the introduction of novel liquid embolic agents, have markedly bolstered EVT's role in managing ACF-dAVFs, with notable series published in the last five years. We aimed to assess the feasibility, safety, and efficacy of EVT for ACF-dAVFs. We searched Medline, Scopus, Web of Science, and Cochrane Library databases following PRISMA guidelines. Eligible studies included those with ≥ 5 patients undergoing embolization of ACF-dAVFs, detailing both angiographic and clinical outcomes. We used single proportion analysis with 95% confidence intervals under a random-effects model, I2 to assess heterogeneity, and Baujat and sensitivity analysis to address high heterogeneity. Publication bias was assessed by funnel-plot analysis and Egger's test. Outcomes included complete occlusion following embolization, unsuccessful endovascular embolization attempts, incomplete occlusion following embolization, symptom resolution or clinical improvement following embolization, recurrence; procedure-related complications, morbidity, and mortality. Additionally, a subanalysis for studies exclusively utilizing Onyx™ embolic system was done. Eighteen studies comprising 231 ACF-dAVF were included. Unsuccessful endovascular embolization attempts rate was 2%. Complete occlusion rate was 85%, with 4% of complications. Incomplete occlusion rate was 10%. Successfully embolized patients experienced either symptom resolution or clinical improvement in 94% of cases. Morbidity and mortality rates were 1% and 0%, respectively. Onyx subanalyses showed an overall rate of 0% for unsuccessful attempts, 95% for complete occlusion, and 5% for incomplete occlusion. Symptom resolution or clinical improvement was 98% and recurrence rate was 0%. EVT for ACF-dAVF is highly feasible, effective, and safe, with a low rate of complications, morbidity, and mortality. The subanalyses focusing on Onyx embolizations revealed superior efficacy and safety outcomes compared to the findings of the primary analyses involving all included studies.

Transarterial Embolization of Anterior Cranial Fossa Dural AVFs as a First-Line Approach: A Single-Center Study

BACKGROUND AND PURPOSE

Endovascular treatment has been increasingly used for anterior cranial fossa dural AVFs. Evidence on the safety and efficacy of different endovascular treatment strategies is limited. We report clinical and angiographic outcomes of patients with anterior cranial fossa dural AVFs who underwent treatment using transarterial embolization with n-BCA as a first-line approach.

MATERIALS AND METHODS

Consecutive patients undergoing treatment for anterior cranial fossa dural AVFs at the Amsterdam University Medical Centers between 2010 and 2023 were retrospectively included. Transarterial embolization was used as a first-line approach, while transvenous treatment and surgery were used in cases of unsuccessful transarterial embolization. Treatment was evaluated on the basis of the angiographic cure rate, procedural complications, and clinical outcome.

RESULTS

Fourteen patients were included with 15 anterior cranial fossa dural AVFs. All patients underwent primary endovascular treatment (12 transarterial, 1 transvenous, and 1 combined). Complete occlusion using only transarterial embolization was reached in 69% of patients (9/13), while the overall complete occlusion by endovascular treatment was reached in 79% of patients (11/14). Navigation and embolization were performed through the ophthalmic artery in 13 patients, with no procedural complications. Visual acuity was preserved in all patients. Three patients underwent an operation after failed endovascular treatment. All patients had complete anterior cranial fossa dural AVF occlusion at follow-up.

CONCLUSIONS

Treatment of anterior cranial fossa dural AVFs using transarterial embolization with n-BCA as a first-line approach is a safe and feasible first-line treatment strategy. No visual complications due to embolization through the ophthalmic artery occurred in this study.

Trans-arterial embolization of anterior cranial fossa dural arteriovenous fistulas via the sphenopalatine artery: a technique report

BACKGROUND

Trans-arterial embolization (TAE) via the ophthalmic artery and middle meningeal arterial are the common arterial routes for anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs). However, TAE via the sphenopalatine artery (SPA) to treat ACF DAVFs is rarely reported. Here, we describe 14 cases of ACF DAVFs that were either treated solely or in conjunction with other arterial routes via the SPA. A total of 15 embolization attempts were performed via the SPA.

METHOD

14 patients were treated with TAE via the SPA over a 20-year period. There were 13 males and 1 female in total, with a mean age of 57.4 (57.4±6.0) years. The clinical presentation, angiographic features, treatment strategy, and clinical outcomes were all documented.

RESULTS

14 patients with ACF DAVFs underwent TAE via the SPA. Complete immediate angiographic occlusion was achieved in 78.6% of the fistulas (11/14). Complete embolization via the SPA alone was achieved in 63.6% (7/11) of the fistulas. A total of 15 embolization attempts were performed via the SPA, with a 46.7% (7/15) success rate. After TAE via the SPA, no complications were found. 42.9% (6/14) of the patients had DSA or MRA follow-up. There was no recurrence of the fistulas.

CONCLUSIONS

The SPA may be as an alternative arterial route if other appropriate arterial routes are unavailable. However, its safety and efficiency need to be confirmed further.

Dural Arteriovenous Fistulas With Cognitive Impairment: Angiographic Characteristics and Treatment Outcomes

BACKGROUND AND OBJECTIVES

Anecdotal cases of rapidly progressing dementia in patients with dural arteriovenous fistulas (dAVFs) have been reported in small series. However, large series have not characterized these dAVFs. We conducted an analysis of the largest cohort of dAVFs presenting with cognitive impairment (dAVFs-CI), aiming to provide a detailed characterization of this subset of dAVFs.

METHODS

Patients with dAVFs-CI were analyzed from the CONDOR Consortium, a multicenter repository comprising 1077 dAVFs. A propensity score matching analysis was conducted to compare dAVFs-CI with Borden type II and type III dAVFs without cognitive impairment (controls). Logistic regression was used to identify angiographic characteristics specific to dAVFs-CI. Furthermore, post-treatment outcomes were analyzed.

RESULTS

A total of 60 patients with dAVFs-CI and 60 control dAVFs were included. Outflow obstruction leading to venous hypertension was observed in all dAVFs-CI. Sinus stenosis was significantly associated with dAVFs-CI (OR 2.85, 95% CI: 1.16-7.55, P = .027). dAVFs-CI were more likely to have a higher number of arterial feeders (OR 1.56, 95% CI 1.22-2.05, P < .001) and draining veins (OR 2.05, 95% CI 1.05-4.46, P = .004). Venous ectasia increased the risk of dAVFs-CI (OR 2.38, 95% CI 1.13-5.11, P = .024). A trend toward achieving asymptomatic status at follow-up was observed in patients with successful closure of dAVFs (OR 2.86, 95% CI 0.85-9.56, P = .09).

CONCLUSION

Venous hypertension is a key angiographic feature of dAVFs-CI. Moreover, these fistulas present at a mean age of 58 years-old, and exhibit a complex angioarchitecture characterized by an increased number of arteriovenous connections and stenosed sinuses. The presence of venous ectasia further exacerbates the impaired drainage and contributes to the development of dAVFs-CI. Notably, in certain cases, closure of the dAVF has the potential to reverse symptoms.