Gamma knife radiosurgery for dural arteriovenous fistulas.

Abstract

The current management of intracranial dural arteriovenous fistulas (dAVFs) incorporates a multimodal approach involving microneurosurgery, endovascular embolization, and radiosurgery. To explore the role of Gamma Knife radiosurgery for dAVFs. The series includes patients with dAVFs who had Gamma Knife radiosurgery at the University of Virginia Medical Center between 1989 and 2005 with clinical follow-up through 2008. Medical records were reviewed to obtain clinical history, demographic data, and dosimetry. Radiographic records provided the location and anatomy of the dAVFs. Follow-up angiography was performed 2 to 3 years after treatment, with cure defined as complete obliteration of fistulous flow. Follow-up for clinical symptomology and quality of life was obtained from direct patient and primary physician questionnaires. Fifty-five patients underwent Gamma Knife radiosurgery for dAVFs during the study period. Twenty patients (36%) presented with intracranial hemorrhage before radiosurgery. Gamma Knife radiosurgery was preceded by craniotomy for microneurosurgical ablation in 11 patients (20%) or endovascular embolization in 36 patients (65%). Follow-up angiography was performed on 46 patients (83%) with documented obliteration in 30 patients (65%). Patients lost to follow-up were classified as treatment failures, adjusting the range of efficacy from 65% to 54%. Three patients (5%) suffered a posttreatment hemorrhage during the follow-up period, but no new permanent neurological deficits resulted from these events. Gamma Knife radiosurgery is an effective adjunct therapy for dAVFs with persistence of flow after open neurosurgical resection or endovascular treatment while still maintaining a role in nonaggressive dAVFs not amenable to either surgery or embolization.