Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan.
J Neurosurg. 2012 Dec;117 Suppl:158-63. doi: 10.3171/2012.7.GKS12967.
The goal of this study was to assess the efficacy of Gamma Knife surgery (GKS) in the management of dural arteriovenous fistulas (dAVFs).
The authors performed a retrospective analysis of a group of 22 patients who underwent GKS for dAVFs at the University of Tokyo Hospital between 1991 and 2009. The patients underwent CT or MR imaging with contrast enhancement every 6 months after GKS; when obliteration of a dAVF was indicated by these images, patients also underwent angiography. Follow-up in these patients ranged from 12 months to 100 months (median 33 months) after GKS.
Obliteration of the dAVF was confirmed by neuroimaging in 12 patients (55%). According to a Kaplan-Meier analysis, obliteration rates for the dAVFs were 51% at 3 years and 80% at 5 years. The obliteration rate for lesions without cortical venous drainage (CVD) was 86%, which was significantly higher than the rate for dAVFs with CVD (47%) (p = 0.007). Hemorrhage at presentation (p = 0.03), a target volume less than 1.5 cm(3) (p = 0.009), and Cognard Type III or IV dAVF (p = 0.005) were factors associated with a higher obliteration rate. Among 10 patients whose dAVFs were not obliterated by the initial GKS, 5 patients underwent additional treatment and complete obliteration was achieved in all. Relief of tinnitus was obtained in 5 (83%) of 6 patients with transverse-sigmoid sinus dAVFs, and ophthalmic symptoms improved in 2 (67%) of 3 patients with cavernous sinus dAVFs. No patient experienced interval hemorrhage or radiation-induced complications after treatment.
Gamma Knife surgery is a safe and effective treatment for dAVF. It can be a first line of therapy in the multidisciplinary treatment strategy for dAVFs, especially when significant morbidity is anticipated with other therapeutic options. One should be very careful about recommending GKS for patients harboring dAVFs with CVD because of the expected natural history of such a lesion and the possibility of other therapeutic options.
本研究旨在评估伽玛刀手术（GKS）治疗硬脑膜动静脉瘘（dAVF）的疗效。
作者对 1991 年至 2009 年期间在东京大学医院接受 GKS 治疗的 22 例 dAVF 患者进行了回顾性分析。患者在 GKS 后每 6 个月进行 CT 或 MRI 增强检查；当这些图像显示 dAVF 闭塞时，患者还进行血管造影检查。这些患者的随访时间从 GKS 后 12 个月到 100 个月（中位数 33 个月）不等。
12 例患者（55%）通过神经影像学证实 dAVF 闭塞。根据 Kaplan-Meier 分析，dAVF 的闭塞率在 3 年内为 51%，在 5 年内为 80%。无皮质静脉引流（CVD）的病变闭塞率为 86%，明显高于有 CVD 的 dAVF（47%）（p=0.007）。首发时出血（p=0.03）、靶体积小于 1.5cm3（p=0.009）和 Cognard Ⅲ或Ⅳ型 dAVF（p=0.005）是与更高闭塞率相关的因素。在 10 例初始 GKS 未能闭塞的患者中，5 例接受了额外治疗，所有患者均完全闭塞。6 例横窦乙状窦 dAVF 患者中有 5 例（83%）耳鸣缓解，3 例海绵窦 dAVF 患者中有 2 例（67%）眼部症状改善。治疗后无患者出现间隔性出血或放射性并发症。
伽玛刀手术是治疗 dAVF 的一种安全有效的方法。在 dAVF 的多学科治疗策略中，它可以作为一线治疗方法，特别是在其他治疗选择可能带来显著发病率的情况下。对于患有 CVD 的 dAVF 患者，由于这种病变的预期自然史和其他治疗选择的可能性，推荐 GKS 时应非常谨慎。
