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.

Barrow Neurological Institute Phoenix Arizona USA

Biostatistics and Data Science The University of Texas Health Science Center at Houston Houston Texas USA

Case Western Reserve University School of Medicine Cleveland Ohio USA

Department of Neurological Surgery University of California San Francisco San Francisco California USA

Department of Neurological Surgery University of Pittsburgh Pittsburgh Pennsylvania USA

Department of Neurology University Medical Centre Groningen Groningen The Netherlands

Department of Neurology University of Iowa Health Care Iowa City Iowa USA

Department of Neurosurgery Barrow Neurological Institute Phoenix Arizona USA

Department of Neurosurgery Koç University Graduate School of Health Sciences Istanbul İstanbul Turkey

Department of Neurosurgery Mayo Clinic Rochester Minnesota USA

Department of Neurosurgery Neurological Institute Taipei Veterans General Hospital Taipei Japan

Department of Radiology and Medical Imaging University of Virginia Charlottesville Virginia USA

Department of Radiology Taipei Veterans General Hospital Taipei Taiwan

Internal Medicine The University of Texas Health Science Center at Houston Houston Texas USA

Neuroimaging Center University Medical Centre Groningen Groningen The Netherlands

Neurological Surgery University of Washington School of Medicine Seattle Washington USA

Neurology and Neurointerventional Radiology University of Iowa Health Care Iowa City Iowa USA

Neurosurgery Brigham and Women's Hospital Boston Massachusetts USA

Neurosurgery Dokkyo Medical University Shimotsuga District Japan

Neurosurgery Norton Healthcare Louisville Kentucky USA

Neurosurgery NYU Langone Medical Center New York New York USA

Neurosurgery Post Graduate Institute of Medical Education and Research Chandigarh Delhi India

Neurosurgery The University of Texas Health Science Center at Houston Houston Texas USA

Neurosurgery The University of Texas Southwestern Medical Center Dallas Texas USA

Neurosurgery Tokushima University Tokushima Tokushima Prefecture Japan

Neurosurgery University at Buffalo Buffalo New York USA

Neurosurgery University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre Southampton England UK

Neurosurgery University of Florida Gainesville Florida USA

Neurosurgery University of Groningen Groningen GR Netherlands

Neurosurgery University of Illinois Chicago Chicago Illinois USA

Neurosurgery University of Miami Health System Miami Florida USA

Neurosurgery University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA

Neurosurgery University of Virginia Charlottesville Virginia USA

Neurosurgery Washington University School of Medicine in Saint Louis Saint Louis Missouri USA

Radiation Oncology NYU Langone Medical Center New York New York USA

Radiation Oncology University of Pittsburgh Pittsburgh Pennsylvania USA

Radiology Mayo Clinic Rochester Minnesota USA

School of Medicine National Yang Ming University Hsinchu Taiwan Province Taiwan

Stereotactic and Radiation Neurosurgery Na Homolce Hospital Prague Czech Republic

University Hospitals Cleveland Medical Center Cleveland Ohio USA

University of Florida Gainesville Florida USA

Washington University School of Medicine in Saint Louis St Louis Missouri USA

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