Gamma Knife surgery for the management of intracranial dural arteriovenous fistulas.
OBJECTIVE
The purpose of this study was to assess the efficacy and safety of Gamma Knife surgery (GKS) for the treatment of cavernous sinus dural arteriovenous fistulas (CSDAVFs) and other intracranial dural arteriovenous fistulas (ODAVFs).


METHODS
Among the 238 GKS procedures performed for intracranial DAVFs in the authors' institute, 227 cases (146 CSDAVFs and 81 OIDAVFs) with clinical follow up formed the database from which the authors determined clinical outcome and the incidence of untoward events. One hundred ninety-five cases (118 CSDAVFs and 77 ODAVFs) with imaging follow up formed the database from which the authors determined the imaging results. Older age, female sex, higher incidence of diabetes, and shorter duration of symptoms were noted more in cases of CSDAVF than in ODAVFs. Most patients had symptomatic improvement after GKS. A symptomatic cure was observed in one patient with CSDAVFs as early as 6 weeks. The cumulative cure rate based on follow-up angiography of CSDAVFs approached 75% at 24 months, which was much better than that of ODAVFs (approximately 50% at 24 months). A neuroimaging-based cure lagged behind that of the clinical symptoms. Overall, there were only two nonfatal intracerebral hemorrhages during the follow-up period, both occurring less than 1 week after GKS and both being Cognard Type IIa+b with initial aggressive symptoms. Transient deterioration of neurological status without hemorrhage was noted in six patients with ODAVFs. Thrombosis of the superior ophthalmic vein occurred in 11 patients with CSDAVFs, in two of whom there were unilateral visual impairments. There were three cranial nerve neuropathies: transient in one CSDAVF and one ODAVF involving the jugular foramen, and another one was a CSDAVF previously treated by conventional radiotherapy.


CONCLUSIONS
Gamma Knife surgery provides a safe and effective option for treatment of intracranial DAVFs with a low risk of complications. In cases of DAVFs with benign clinical presentation, GKS can serve as a primary treatment. In some cases of aggressive DAVFs in which there is extensive retrograde cortical vein drainage, combined treatment with embolization or surgery is suggested.
Wu
Hsiu-Mei
HM
Department of Radiology, Taipei Veterans General Hospital, VACRS, Taipei, Taiwan, Republic of China. hmwu@vghtpe.gov.tw
Pan
David Hung-Chi
DH
Chung
Wen-Yuh
WY
Guo
Wan-Yuo
WY
Liu
Kang-Du
KD
Shiau
Cheng-Ying
CY
Wang
Ling-Wei
LW
Chen
Shih-Jen
SJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D020785:Central Nervous System Vascular Malformations / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D015331:Cohort Studies; D003392:Cranial Sinuses; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016634:Radiosurgery; D011880:Radiotherapy Planning, Computer-Assisted; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult