Departments of1Neurological Surgery.
4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington.
J Neurosurg. 2021 Sep 10;136(4):971-980. doi: 10.3171/2021.1.JNS202861. Print 2022 Apr 1.
There is a reported elevated risk of cerebral aneurysms in patients with intracranial dural arteriovenous fistulas (dAVFs). However, the natural history, rate of spontaneous regression, and ideal treatment regimen are not well characterized. In this study, the authors aimed to describe the characteristics of patients with dAVFs and intracranial aneurysms and propose a classification system.
The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database from 12 centers was retrospectively reviewed. Analysis was performed to compare dAVF patients with (dAVF+ cohort) and without (dAVF-only cohort) concomitant aneurysm. Aneurysms were categorized based on location as a dAVF flow-related aneurysm (FRA) or a dAVF non-flow-related aneurysm (NFRA), with further classification as extra- or intradural. Patients with traumatic pseudoaneurysms or aneurysms with associated arteriovenous malformations were excluded from the analysis. Patient demographics, dAVF anatomical information, aneurysm information, and follow-up data were collected.
Of the 1077 patients, 1043 were eligible for inclusion, comprising 978 (93.8%) and 65 (6.2%) in the dAVF-only and dAVF+ cohorts, respectively. There were 96 aneurysms in the dAVF+ cohort; 10 patients (1%) harbored 12 FRAs, and 55 patients (5.3%) harbored 84 NFRAs. Dural AVF+ patients had higher rates of smoking (59.3% vs 35.2%, p < 0.001) and illicit drug use (5.8% vs 1.5%, p = 0.02). Sixteen dAVF+ patients (24.6%) presented with aneurysm rupture, which represented 16.7% of the total aneurysms. One patient (1.5%) had aneurysm rupture during follow-up. Patients with dAVF+ were more likely to have a dAVF located in nonconventional locations, less likely to have arterial supply to the dAVF from external carotid artery branches, and more likely to have supply from pial branches. Rates of cortical venous drainage and Borden type distributions were comparable between cohorts. A minority (12.5%) of aneurysms were FRAs. The majority of the aneurysms underwent treatment via either endovascular (36.5%) or microsurgical (15.6%) technique. A small proportion of aneurysms managed conservatively either with or without dAVF treatment spontaneously regressed (6.2%).
Patients with dAVF have a similar risk of harboring a concomitant intracranial aneurysm unrelated to the dAVF (5.3%) compared with the general population (approximately 2%-5%) and a rare risk (0.9%) of harboring an FRA. Only 50% of FRAs are intradural. Dural AVF+ patients have differences in dAVF angioarchitecture. A subset of dAVF+ patients harbor FRAs that may regress after dAVF treatment.
据报道，颅内硬脑膜动静脉瘘（dAVF）患者发生脑动脉瘤的风险升高。然而，其自然病史、自发消退率和理想的治疗方案尚未得到很好的描述。在这项研究中，作者旨在描述伴有和不伴有颅内动脉瘤的 dAVF 患者的特征，并提出一种分类系统。
回顾了来自 12 个中心的 Consortium for Dural Arteriovenous Fistula Outcomes Research（CONDOR）数据库。分析旨在比较伴有（dAVF+ 队列）和不伴有（dAVF-仅队列）伴随动脉瘤的 dAVF 患者。根据位置将动脉瘤分为 dAVF 血流相关动脉瘤（FRA）或 dAVF 非血流相关动脉瘤（NFRA），进一步分为硬膜内或硬膜外。排除了创伤性假性动脉瘤或伴有动静脉畸形的动脉瘤患者。收集患者的人口统计学、dAVF 解剖信息、动脉瘤信息和随访数据。
在 1077 名患者中，有 1043 名符合纳入标准，其中 978 名（93.8%）和 65 名（6.2%）分别在 dAVF-仅队列和 dAVF+队列中。dAVF+队列中有 96 个动脉瘤；10 名患者（1%）存在 12 个 FRA，55 名患者（5.3%）存在 84 个 NFRAs。dAVF+患者中吸烟率（59.3% vs. 35.2%，p<0.001）和非法药物使用率（5.8% vs. 1.5%，p=0.02）更高。16 名 dAVF+患者（24.6%）出现动脉瘤破裂，占总动脉瘤的 16.7%。1 名患者（1.5%）在随访期间出现动脉瘤破裂。dAVF+患者更可能存在位于非传统位置的 dAVF，较少存在来自颈外动脉分支的 dAVF 动脉供应，更可能存在来自脑膜分支的供应。皮质静脉引流和 Borden 类型分布的比率在两组之间相似。少数（12.5%）的动脉瘤为 FRA。大多数动脉瘤通过血管内（36.5%）或显微手术（15.6%）技术进行治疗。少数（6.2%）动脉瘤经保守治疗（伴或不伴 dAVF 治疗）自发消退。
与普通人群（约 2%-5%）相比，dAVF 患者伴有颅内动脉瘤的风险相似（5.3%），而伴有 FRA 的风险罕见（0.9%）。只有 50%的 FRA 位于硬脑膜内。dAVF+患者的 dAVF 血管结构存在差异。一部分 dAVF+患者伴有可能在 dAVF 治疗后消退的 FRA。
