Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, P.B. 0454 Nydalen, 0424, Oslo, Norway.
Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
Acta Neurochir (Wien). 2022 Jan;164(1):151-161. doi: 10.1007/s00701-021-04950-9. Epub 2021 Sep 6.
Cranial dural arteriovenous fistulas (dAVFs) are rare lesions managed mainly with endovascular treatment (EVT) and/or surgery. We hypothesize that there may be subtypes of dAVFs responding better to a specific treatment modality in terms of successful obliteration and cessation of symptoms and/or risks.
All dAVFs treated during 2011-2018 at our hospital were analyzed retrospectively. Presenting symptoms, radiological variables, treatment modality, complications, and residual symptoms were related to dAVF type using the original Djindjian classification.
We treated 112 dAVFs in 107 patients (71, 66% males). They presented with hemorrhage (n = 23; 21%), non-hemorrhagic symptoms (n = 75; 70%), or were discovered incidentally (n = 9; 8%). There were 25 (22%) type I, 29 (26%) type II, 26 (23%) type III, and 32 (29%) type IV fistulas. EVT was the primary treatment modality in 72/112 (64%) dAVFs whereas 40/112 (36%) underwent primary surgery with angiographic obliteration rates of 60% and 90%, respectively. Using a secondary treatment modality in 23 dAVFs, we obtained a final obliteration rate of 93%, including all type III/IV and 26/27 (96%) type II dAVFs. Except for headache, residual symptoms were rare and minor. Permanent neurological complications consisted of five cranial nerve deficits.
We recommend EVT as first treatment modality in types I, II, and in non-hemorrhagic type III/IV dAVFs. We recommend surgery as first treatment choice in acute hemorrhagic dAVFs and as secondary choice in type III/IV dAVFs not successfully occluded by EVT. Combining the two modalities provides obliteration in 9/10 dAVF cases at a low procedural risk.
颅内外沟通性动静脉瘘（dAVF）是一种罕见的病变，主要通过血管内治疗（EVT）和/或手术治疗。我们假设，根据闭塞成功率、症状和/或风险的缓解情况，可能存在对特定治疗方式反应更好的 dAVF 亚型。
对我院 2011-2018 年期间治疗的所有 dAVF 进行回顾性分析。使用原始 Djindjian 分类法，将患者的临床表现、影像学变量、治疗方式、并发症和残留症状与 dAVF 类型相关联。
我们共治疗了 107 例（71 例，66%为男性）患者的 112 例 dAVF。其中，23 例（21%）患者出现出血，75 例（70%）患者出现非出血性症状，9 例（8%）患者为偶然发现。25 例（22%）为 1 型，29 例（26%）为 2 型，26 例（23%）为 3 型，32 例（29%）为 4 型。72/112 例（64%）的 dAVF 采用 EVT 作为主要治疗方法，40/112 例（36%）采用血管造影闭塞率分别为 60%和 90%的手术作为主要治疗方法。在 23 例 dAVF 中采用二线治疗方法，最终闭塞率达到 93%，包括所有 3 型/4 型和 26/27（96%）型 2 型 dAVF。除头痛外，残留症状少见且轻微。永久性神经并发症包括 5 例颅神经缺陷。
我们建议 EVT 作为 1 型、2 型和非出血性 3 型/4 型 dAVF 的首选治疗方法。我们建议将手术作为急性出血性 dAVF 的首选治疗方法，并作为 EVT 未能成功闭塞的 3 型/4 型 dAVF 的二线治疗方法。两种方法相结合可使 9/10 的 dAVF 病例在低操作风险下得到闭塞。
