BACKGROUND: There are presently no grading scales that specifically address the outcomes of cranial dural arteriovenous fistula (dAVF) after stereotactic radiosurgery (SRS). OBJECTIVE: To design a practical grading system that would predict outcomes after SRS for cranial dAVFs. METHODS: From the International Radiosurgery Research Foundation (University of Pittsburgh [41 patients], University of Pennsylvania [6 patients], University of Sherbrooke [2 patients], University of Manitoba [1 patient], West Virginia University [2 patients], University of Puerto Rico [1 patient], Beaumont Health System 1 [patient], Na Homolce Hospital [13 patients], the University of Virginia [48 patients], and Yale University [6 patients]) centers, 120 patients with dAVF treated with SRS were included in the study. The factors predicting favorable outcome (obliteration without post-SRS hemorrhage) after SRS were assessed using logistic regression analysis. These factors were pooled with the factors that were found to be predictive of obliteration from 7 studies with 736 patients after a systematic review of literature. These were entered into stepwise multiple regression and the best-fit model was identified. RESULTS: Based on the predictive model, 3 factors emerged to develop an SRS scoring system: cortical venous reflux (CVR), prior intracerebral hemorrhage (ICH), and noncavernous sinus location. Class I (score of 0-1 points) predicted the best favorable outcome of 80%. Class II patients (2 points score) had an intermediate favorable outcome of 57%, and class III (score 3 points) had the least favorable outcome at 37%. The ROC analysis showed better predictability to prevailing grading systems (AUC = 0.69; P = .04). Kaplan-Meier analysis showed statistically significant difference between the 3 subclasses of the proposed grading system for post-SRS dAVF obliteration (P = .001). CONCLUSION: The proposed dAVF grading system incorporates angiographic, anatomic, and clinical parameters and improves the prediction of the outcomes following SRS for dAVF as compared to the existing scoring systems.

Department of Neurological Surgery Na Homolce Hospital Prague Czech Republic

Department of Neurological Surgery Université de Sherbrooke Centre de recherche du CHUS Sherbrooke Canada

Department of Neurological Surgery University of Manitoba Winnipeg Canada

Department of Neurological Surgery University of Pennsylvania Philadelphia Pennsylvania

Department of Neurological Surgery University of Pittsburgh Pittsburgh Pennsylvania

Department of Neurological Surgery University of Puerto Rico San Juan Puerto Rico

Department of Neurological Surgery University of Virginia Charlottesville Virginia

Department of Neurological Surgery West Virginia University Morgantown West Virginia

Department of Radiation Oncology Beaumont Health System Royal Oak Michigan

School of Medicine Yale University New Haven Connecticut

Zobrazit více v PubMed

Borden JA, Wu JK, Shucart WA. A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg. 1995;82(2):166-179. PubMed

Cognard C, Gobin YP, Pierot L et al. .. Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology. 1995;194(3):671-680. PubMed

Zipfel GJ, Shah MN, Refai D, Dacey RG, Derdeyn CP. Cranial dural arteriovenous fistulas: modification of angiographic classification scales based on new natural history data. Neurosurg Focus. 2009;26(5):E14. PubMed

Cifarelli CP, Kaptain G, Yen C-P, Schlesinger D, Sheehan JP. Gamma knife radiosurgery for dural arteriovenous fistulas. Neurosurgery. 2010;67(5):1230-1235; discussion 1235. PubMed

Söderman M, Edner G, Ericson K et al. .. Gamma knife surgery for dural arteriovenous shunts: 25 years of experience. J Neurosurg. 2006;104(6):867-875. PubMed

Chen C-J, Lee C-C, Ding D et al. .. Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review. J Neurosurg. 2015;122(2):353-362. PubMed

Starke RM, McCarthy DJ, Chen C-J et al. .. Evaluation of stereotactic radiosurgery for cerebral dural arteriovenous fistulas in a multicenter international consortium. J Neurosurg. published online: January2019(doi: 10.3171/2018.8.JNS181467). PubMed PMC

Mohammed N, Ding D, Hung Y-C et al. .. Primary versus postoperative stereotactic radiosurgery for acromegaly: a multicenter matched cohort study. J Neurosurg. published online: April2019(doi: 10.3171/2019.1.JNS183398). PubMed PMC

DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837-845. PubMed

Guo WY, Pan DH, Wu HM et al. .. Radiosurgery as a treatment alternative for dural arteriovenous fistulas of the cavernous sinus. AJNR Am J Neuroradiol. 1998;19(6):1081-1087. PubMed PMC

Barcia-Salorio JL, Soler F, Barcia JA, Hernández G. Stereotactic radiosurgery for the treatment of low-flow carotid-cavernous fistulae: results in a series of 25 cases. Stereotact Funct Neurosurg. 1994;63(1-4):266-270. PubMed

Pollock BE, Nichols DA, Garrity JA, Gorman DA, Stafford SL. Stereotactic radiosurgery and particulate embolization for cavernous sinus dural arteriovenous fistulae. Neurosurgery. 1999;45(3):459-466; discussion 466-467. PubMed

Yang H-C, Kano H, Kondziolka D et al. .. Stereotactic radiosurgery with or without embolization for intracranial dural arteriovenous fistulas. Neurosurgery. 2010;67(5):1276-1283; discussion 1284-1285. PubMed

Friedman JA, Pollock BE, Nichols DA, Gorman DA, Foote RL, Stafford SL. Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses. J Neurosurg. 2001;94(6):886-891. PubMed

Koebbe CJ, Singhal D, Sheehan J et al. .. Radiosurgery for dural arteriovenous fistulas. Surg Neurol. 2005;64(5):392-398; discussion 398-399. PubMed

Link MJ, Coffey RJ, Nichols DA, Gorman DA. The role of radiosurgery and particulate embolization in the treatment of dural arteriovenous fistulas. J Neurosurg. 1996;84(5):804-809. PubMed

Wu H-M, Pan DH-C, Chung W-Y et al. .. Gamma knife surgery for the management of intracranial dural arteriovenous fistulas. J Neurosurg. 2006;105(Suppl):43-51. PubMed

Pan DH, Chung W, Guo W et al. .. Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse-sigmoid sinus. J Neurosurg. 2002;96(5):823-829. PubMed

Kida Y. Radiosurgery for dural arteriovenous fistula. Prog Neurol Surg. 2009;22:38-44(doi:10.1159/000163381). PubMed

Park S-H, Park K-S, Kang D-H, Hwang J-H, Hwang S-K. Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: its clinical and angiographic perspectives. Acta Neurochir. 2017;159(6):1093-1103. PubMed

Chung SJ, Kim JS, Kim JC et al. .. Intracranial dural arteriovenous fistulas: analysis of 60 patients. Cerebrovasc Dis. 2002;13(2):79-88. PubMed

Hanakita S, Koga T, Shin M, Shojima M, Igaki H, Saito N. Role of Gamma knife surgery in the treatment of intracranial dural arteriovenous fistulas. J Neurosurg. 2012;117(Suppl):158-163. PubMed

Piippo A, Laakso A, Seppä K et al. .. Early and long-term excess mortality in 227 patients with intracranial dural arteriovenous fistulas. J Neurosurg. 2013;119(1):164-171. PubMed

Schneider BF, Eberhard DA, Steiner LE. Histopathology of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg. 1997;87(3):352-357. PubMed

Tonetti DA, Gross BA, Jankowitz BT et al. .. Reconsidering an important subclass of high-risk dural arteriovenous fistulas for stereotactic radiosurgery. J Neurosurg. 2018;130(3):972-976. PubMed

Strom RG, Botros JA, Refai D et al. .. Cranial dural arteriovenous fistulae: asymptomatic cortical venous drainage portends less aggressive clinical course. Neurosurgery. 2009;64(2):241-247; discussion 247-248. PubMed

Söderman M, Pavic L, Edner G, Holmin S, Andersson T. Natural history of dural arteriovenous shunts. Stroke. 2008;39(6):1735-1739. PubMed

van Rooij WJ, Sluzewski M. Curative embolization with Onyx of dural arteriovenous fistulas with cortical venous drainage. AJNR Am J Neuroradiol. 2010;31(8):1516-1520. PubMed PMC

Macdonald JHM, Millar JS, Barker CS. Endovascular treatment of cranial dural arteriovenous fistulae: a single-centre, 14-year experience and the impact of Onyx on local practise. Neuroradiology. 2010;52(5):387-395. PubMed

Mohammed N, Hung Y-C, Xu Z et al. .. A propensity score-matched cohort analysis of outcomes after stereotactic radiosurgery in older versus younger patients with dural arteriovenous fistula: an international multicenter study. World Neurosurg. published online: February2019(doi: 10.1016/j.wneu.2019.01.253). PubMed PMC

Lewis AI, Tomsick TA, Tew JM. Management of tentorial dural arteriovenous malformations: transarterial embolization combined with stereotactic radiation or surgery. J Neurosurg. 1994;81(6):851-859. PubMed

Lucas CP, Zabramski JM, Spetzler RF, Jacobowitz R. Treatment for intracranial dural arteriovenous malformations: a meta-analysis from the English language literature. Neurosurgery. 1997;40(6):1119-1130; discussion 1130-1132. PubMed