J Stroke.  2022 May;24(2):278-287. 10.5853/jos.2021.03594.

A Practical Grading Scale for Predicting Outcomes of Radiosurgery for Dural Arteriovenous Fistulas: JLGK 1802 Study

• Hasegawa H
• Shin M
• Kawagishi J
• Jokura H
• Hasegawa T
• Kato T
• Kawashima M
• Shinya Y
• Kenai H
• Kawabe T
• Sato M
• Serizawa T
• Nagano O
• Aoyagi K
• Kondoh T
• Yamamoto M
• Onoue S
• Nakazaki K
• Iwai Y
• Yamanaka K
• Hasegawa S
• Kashiwabara K
• Saito N
• on Behalf of the JLGK 1802 Study Group

• KMID: 2530530
• DOI: http://doi.org/10.5853/jos.2021.03594

Abstract

Background and Purpose
To assess the long-term outcomes of intracranial dural arteriovenous fistula (DAVF) treated with stereotactic radiosurgery (SRS) alone or embolization and SRS (Emb-SRS) and to develop a grading system for predicting DAVF obliteration.
Methods
This multi-institutional retrospective study included 200 patients with DAVF treated with SRS or Emb-SRS. We investigated the long-term obliteration rate and obliteration-associated factors. We developed a new grading system to estimate the obliteration rate. Additionally, we compared the outcomes of SRS and Emb-SRS by using propensity score matching.
Results
The 3- and 4-year obliteration rates were 66.3% and 78.8%, respectively. The post-SRS hemorrhage rate was 2%. In the matched cohort, the SRS and Emb-SRS groups did not differ in the rates of obliteration (P=0.54) or post-SRS hemorrhage (P=0.50). In multivariable analysis, DAVF location and cortical venous reflux (CVR) were independently associated with obliteration. The new grading system assigned 2, 1, and 0 points to DAVFs in the anterior skull base or middle fossa, DAVFs with CVR or DAVFs in the superior sagittal sinus or tentorium, and DAVFs without these factors, respectively. Using the total points, patients were stratified into the highest (0 points), intermediate (1 point), or lowest (≥2 points) obliteration rate groups that exhibited 4-year obliteration rates of 94.4%, 71.3%, and 60.4%, respectively (P<0.01).
Conclusions
SRS-based therapy achieved DAVF obliteration in more than three-quarters of the patients at 4 years of age. Our grading system can stratify the obliteration rate and may guide physicians in treatment selection.

Keyword

Central nervous system vascular malformations; Hemorrhagic stroke; Gamma knife radiosurgery; Radiosurgery

Figure

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  Figure 1. Kaplan-Meier curves of fistula obliteration rates. (A) Entire cohort, (B) female vs. male, (C) presence vs. absence of cortical venous reflux (CVR), (D) sinus type vs. non-sinus type, (E) per fistula location, (F) per location category. SRS, stereotactic radiosurgery; CS, cavernous sinus; TS, transverse-sigmoid; SSS, superior sagittal sinus; ASB, anterior skull base; MF, middle fossa; Tent, tentorial.

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  Figure 2. Kaplan–Meier curves of fistula obliteration rates in the matched cohort. Emb-SRS, embolization with SRS; SRS, stereotactic radiosurgery

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  Figure 3. Radiosurgical grading system for dural arteriovenous fistulas (DAVFs). (A) Schematic drawing of the radiosurgical DAVF grading system. (B) Kaplan-Meier curves showing rates of fistula obliteration stratified by the radiosurgical DAVF grading system. CVR, cortical venous reflux; SSS, superior sagittal sinus; ASB, anterior skull base; MF, middle fossa; SRS, stereotactic radiosurgery.

Reference

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