Stereotactic radiosurgery versus observation for intracranial low-grade dural arteriovenous fistulas

Andrea Becerril-Gaitan; Pedram Peesh; Collin Liu; Cheng-Chia Lee; Huai-Che Yang; Ajay Niranjan; Lawrence Dade Lunsford; Zhishuo Wei; Andrew Hoang; Jason Sheehan; Samantha Dayawansa; Selçuk Peker; Yavuz Samanci; Robert M Starke; Ahmed Abdelsalam; Douglas Kondziolka; Kenneth Bernstein; Ying Ming; Go Ikeda; Hideyuki Kano; Manjul Tripathi; Roman Liscak; Jaromir May; Qian Wang; Wen Li; Babu Welch; Jennifer O'Con; Sepideh Amin-Hanjani; Quang Nguyen; Guiseppe Lanzino; Waleed Brinjikji; Minako Hayakawa; Edgar Samaniego; Rose Du; Rosalind Lai; Colin Derdeyn; Adib Abla; Bradley Gross; Felipe Albuquerque; Michael Lawton; Louis Kim; Michael Levitt; Ali Alaraj; Ethan Winkler; Nohra Chalouhi; Brian Hoh; Diederik Bulters; Andrew Durnford; Junichiro Satomi; Yoshiteru Tada; Mark van Dijk; Adriaan R E Potgieser; Dimitri Laurent; Josh Osbun; Brigette Bahmani; Gregory Zipfel; Ching-Jen Chen

doi:10.1136/jnnp-2024-335675

Stereotactic radiosurgery versus observation for intracranial low-grade dural arteriovenous fistulas

J Neurol Neurosurg Psychiatry. 2025 Jun 6:jnnp-2024-335675. doi: 10.1136/jnnp-2024-335675. Online ahead of print.

Authors

Andrea Becerril-Gaitan¹, Pedram Peesh¹, Collin Liu², Cheng-Chia Lee^{3

4}, Huai-Che Yang⁵, Ajay Niranjan⁶, Lawrence Dade Lunsford^{6

7}, Zhishuo Wei⁸, Andrew Hoang⁸, Jason Sheehan⁹, Samantha Dayawansa⁹, Selçuk Peker¹⁰, Yavuz Samanci¹⁰, Robert M Starke¹¹, Ahmed Abdelsalam¹¹, Douglas Kondziolka¹², Kenneth Bernstein¹³, Ying Ming¹², Go Ikeda¹⁴, Hideyuki Kano¹⁴, Manjul Tripathi¹⁵, Roman Liscak¹⁶, Jaromir May¹⁶, Qian Wang¹⁷, Wen Li¹⁸, Babu Welch¹⁹, Jennifer O'Con¹⁹, Sepideh Amin-Hanjani^{20

21}, Quang Nguyen²⁰, Guiseppe Lanzino²², Waleed Brinjikji²³, Minako Hayakawa²⁴, Edgar Samaniego²⁵, Rose Du²⁶, Rosalind Lai²⁶, Colin Derdeyn²⁷, Adib Abla¹¹, Bradley Gross⁸, Felipe Albuquerque²⁸, Michael Lawton²⁹, Louis Kim³⁰, Michael Levitt³⁰, Ali Alaraj³¹, Ethan Winkler³², Nohra Chalouhi³³, Brian Hoh³⁴, Diederik Bulters³⁵, Andrew Durnford³⁵, Junichiro Satomi³⁶, Yoshiteru Tada³⁶, Mark van Dijk³⁷, Adriaan R E Potgieser^{38

39}, Dimitri Laurent⁴⁰, Josh Osbun⁴¹, Brigette Bahmani⁴², Gregory Zipfel⁴¹, Ching-Jen Chen⁴³

Affiliations

¹ Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
² Neurosurgery, University at Buffalo, Buffalo, New York, USA.
³ Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Japan.
⁴ School of Medicine, National Yang-Ming University, Hsinchu, Taiwan Province, Taiwan.
⁵ Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.
⁶ Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
⁷ Radiation Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
⁸ Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
⁹ Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
¹⁰ Department of Neurosurgery, Koç University Graduate School of Health Sciences, Istanbul, İstanbul, Turkey.
¹¹ Neurosurgery, University of Miami Health System, Miami, Florida, USA.
¹² Neurosurgery, NYU Langone Medical Center, New York, New York, USA.
¹³ Radiation Oncology, NYU Langone Medical Center, New York, New York, USA.
¹⁴ Neurosurgery, Dokkyo Medical University, Shimotsuga District, Japan.
¹⁵ Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, Delhi, India.
¹⁶ Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic.
¹⁷ Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
¹⁸ Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
¹⁹ Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.
²⁰ University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
²¹ Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
²² Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.
²³ Radiology, Mayo Clinic, Rochester, Minnesota, USA.
²⁴ Department of Neurology, University of Iowa Health Care, Iowa City, Iowa, USA.
²⁵ Neurology and Neurointerventional Radiology, University of Iowa Health Care, Iowa City, Iowa, USA.
²⁶ Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
²⁷ Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia, USA.
²⁸ Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
²⁹ Barrow Neurological Institute, Phoenix, Arizona, USA.
³⁰ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
³¹ Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA.
³² Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.
³³ Neurosurgery, University of Florida, Gainesville, Florida, USA.
³⁴ University of Florida, Gainesville, Florida, USA.
³⁵ Neurosurgery, University Hospital Southampton NHS Foundation Trust, Wessex Neurological Centre, Southampton, England, UK.
³⁶ Neurosurgery, Tokushima University, Tokushima, Tokushima Prefecture, Japan.
³⁷ Neurosurgery, University of Groningen, Groningen, GR, Netherlands.
³⁸ Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands.
³⁹ Neuroimaging Center, University Medical Centre Groningen, Groningen, The Netherlands.
⁴⁰ Neurosurgery, Norton Healthcare, Louisville, Kentucky, USA.
⁴¹ Neurosurgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.
⁴² Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA.
⁴³ Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA ching-jen.chen@uth.tmc.edu.

PMID: 40480804
DOI: 10.1136/jnnp-2024-335675

Abstract

Background: Given the low haemorrhagic risk of intracranial low-grade dural arteriovenous fistulas (dAVFs), the benefits of routine intervention remain controversial. This study compares patient outcomes treated with stereotactic radiosurgery (SRS) versus conservative management.

Method: Multicentre retrospective analysis of the Consortium for Dural Arteriovenous Fistula Outcomes Research and the International Radiosurgery Research Foundation data. Inclusion criteria were (1) intracranial low-grade dAVF diagnosed by catheter-based angiography, (2) no prior dAVF-related haemorrhage and (3) management with upfront SRS (intervention group) or conservative management (observation group). The primary outcome was symptomatic improvement. Secondary outcomes included dAVF obliteration, up-conversion, haemorrhage, improvement and favourable modified Rankin Scale (mRS) at follow-up.

Results: 304 patients with a mean age of 56 years (SD 13.5) and a follow-up of 46.7 months (SD 45.5) were included. 135 (44.4%) were managed conservatively and 169 (55.6%) had upfront SRS. Compared with the observation group, symptomatic and mRS Score improvement (≥1-point decrease in baseline score) was more likely in the intervention group (95.1% vs 58.5%; OR=13.75 (5.61-33.69) and 37.0% vs 24.0%; OR=1.85 (1.09-3.15), respectively). These findings remained significant after multiple imputation and propensity score matching. Remaining outcomes were similar between groups. The all-cause mortality rate was 5.4% (n=16), unrelated to the dAVF or treatment. Five (3.0%) SRS-related complications were reported and resolved during the follow-up period.

Conclusions: SRS was associated with increased symptomatic and mRS Score improvement for low-grade dAVFs compared with conservative management. SRS had a low complication risk and did not appear to alter dAVF obliteration or haemorrhage. Future prospective trials on SRS as a first-line intervention for symptomatic low-grade dAVFs should be considered.

Keywords: CEREBROVASCULAR; NEURORADIOLOGY; NEUROSURGERY; Patient Outcome Assessment; QUALITY OF LIFE.