Raygor Kunal P, Abdelsalam Ahmed, Tonetti Daniel A, Raper Daniel M S, Guniganti Ridhima, Durnford Andrew J, Giordan Enrico, Brinjikji Waleed, Chen Ching-Jen, Abecassis Isaac Josh, Levitt Michael R, Polifka Adam J, Derdeyn Colin P, Samaniego Edgar A, Kwasnicki Amanda, Alaraj Ali, Potgieser Adriaan R E, Chen Stephanie, Tada Yoshiteru, Kansagra Akash P, Satomi Junichiro, Eatz Tiffany, Peterson Eric C, Starke Robert M, van Dijk J Marc C, Amin-Hanjani Sepideh, Hayakawa Minako, Gross Bradley A, Fox W Christopher, Kim Louis, Sheehan Jason, Lanzino Giuseppe, Du Rose, Lai Pui Man Rosalind, Bulters Diederik O, Zipfel Gregory J, Abla Adib A
Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.
Department of Neurological Surgery, University of Miami, Coral Gables, Florida, USA.
Neurosurgery. 2024 Oct 8. doi: 10.1227/neu.0000000000003204.
First-line therapy for most intracranial dural arteriovenous fistulas (dAVFs) is endovascular embolization, but some require microsurgical ligation due to limited endovascular accessibility, anticipated lower cure rates, or unacceptable risk profiles. We investigated the most common surgically treated dAVF locations and the approaches and outcomes of each.
The Consortium for Dural Arteriovenous Fistula Outcomes Research database was retrospectively reviewed. Patients who underwent dAVF microsurgical ligation were included. Patient demographics, angiographic information, surgical details, and postoperative outcomes were collected. The 5 most common surgically treated dAVF locations were analyzed about used surgical approaches and postoperative outcomes. Univariate analyses were performed with statistical significance set at a threshold of P < .05.
In total, 248 patients in the Consortium for Dural Arteriovenous Fistula Outcomes Research database met inclusion criteria. The 5 most common surgically treated dAVF locations were tentorial, anterior cranial fossa (ACF), transverse-sigmoid sinus (TSS), convexity/superior sagittal sinus (SSS), and torcular. Most tentorial dAVFs were approached using a suboccipital, lateral supracerebellar infratentorial approach (39.3%); extended retrosigmoid approach (ERS) (25%); or posterior subtemporal approach (19.6%). All ACF dAVFs used a subfrontal approach; 5.3% also included an anterior interhemispheric approach. Most TSS dAVFs were ligated via ERS (31.3%) or subtemporal (31.3%) approaches. All convexity/SSS dAVFs used an interhemispheric approach. All torcular dAVFs used the suboccipital, lateral supracerebellar infratentorial approach, with 10.5% undergoing simultaneous ERS craniotomy. Angiographic occlusion rates after microsurgery were 85.5%, 100%, 75.8%, 79.2%, and 73.7% for tentorial, ACF, TSS, convexity/SSS, and torcular dAVFs, respectively (P = .02); the permanent neurological complication rates were 1.8%, 2.6%, 9.1%, 0%, and 0% (P = .31). There were no statistically significant differences in development of complications (P = .08) or Modified Rankin Scale at the last follow-up (P = .11) by fistula location.
Although endovascular embolization is the first-line treatment for most intracranial dAVFs, surgical ligation is an important alternative. ACF and tentorial fistulas particularly demonstrate high rates of postoperative obliteration.
大多数颅内硬脑膜动静脉瘘（dAVF）的一线治疗方法是血管内栓塞，但由于血管内治疗的可及性有限、预期治愈率较低或风险状况不可接受，一些患者需要进行显微外科结扎。我们研究了最常见的接受手术治疗的dAVF部位以及每种部位的手术入路和结果。
对硬脑膜动静脉瘘预后研究联盟数据库进行回顾性分析。纳入接受dAVF显微外科结扎的患者。收集患者的人口统计学资料、血管造影信息、手术细节和术后结果。分析了5个最常见的接受手术治疗的dAVF部位的手术入路和术后结果。进行单因素分析，设定统计学显著性阈值为P < 0.05。
硬脑膜动静脉瘘预后研究联盟数据库中共有248例患者符合纳入标准。5个最常见的接受手术治疗的dAVF部位是天幕、前颅窝（ACF）、横窦-乙状窦（TSS）、凸面/上矢状窦（SSS）和窦汇。大多数天幕dAVF采用枕下外侧小脑上幕下入路（39.3%）；扩大乙状窦后入路（ERS）（25%）；或颞下后入路（19.6%）。所有ACF dAVF均采用额下入路；5.3%还包括经纵裂前部入路。大多数TSS dAVF通过ERS（31.3%）或颞下入路（31.3%）进行结扎。所有凸面/SSS dAVF均采用经纵裂入路。所有窦汇dAVF均采用枕下外侧小脑上幕下入路，10.5%同时行ERS开颅术。显微手术后，天幕、ACF、TSS、凸面/SSS和窦汇dAVF的血管造影闭塞率分别为85.5%、100%、75.8%、79.2%和73.7%（P = 0.02）；永久性神经并发症发生率分别为1.8%、2.6%、9.1%、0%和0%（P = 0.31）。瘘管部位在并发症发生情况（P = 0.08）或最后一次随访时的改良Rankin量表评分（P = 0.11）方面无统计学显著差异。
尽管血管内栓塞是大多数颅内dAVF的一线治疗方法，但手术结扎是一种重要的替代方法。ACF和天幕瘘尤其显示出较高的术后闭塞率。
