multispecialty treatment of dural arteriovenous fistulas: embolization, craniotomy and radiosurgery...
TRANSCRIPT
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Multispecialty Treatment of Dural Arteriovenous Fistulas: Embolization, Craniotomy and Radiosurgery
David Barnett, MDChief of NeurosurgeryBaylor University Medical Center
August 13, 2013 7am
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Goals
• What is a Dural Arteriovenous Fistula (DAVF)?
• How do they present?
• What constitutes a potentially dangerous DAVF?
• The roles of the different treatment options.
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Definition of DAVF
• An arteriovenous shunt in which the nidus is solely contained within the leaflets of the dura mater.
• Also referred to as Dural Arteriovenous Malformation (DAVM).
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Background
• 10-15% of all intercranial AVM
• More common in women
• Mean age at presentation is fifties
• Rare in children
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Pathogensis
• Not completely understood
• Most popular theory is collateral revascularication (i.e. sinus thrombosis followed by recanalization of the dura)
• Precipitating factors include…trauma, hypercoagulable states, and infection
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Presentation
• Highly variable• Location, location, location• Pulsatile tinnitus, Bruit, Headache• Opthalmoplegia, Chemosis, Proptosis• Papilledema• Focal or Global Neurologic Deficit• Intracranial hemorrhage
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Radiographic Evaluation
• CT/CT Angiogram, MR/MR Angiogram• Initial investigation• Abnormal blood vessels, white matter edema, hemorrhage• Cannot exclude DAVF
• Intracranial Angiography• The Gold Standard• Accurate classification
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Hallmark Angiographic Feature
• Premature appearance of venous structures• Within or next to the dura during the arterial phase
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Arterial Supply
• Arterial branches that supply the dura• Middle menigeal artery• Anterior Fossa: Ethmodial branches of the opthalmic
artery• Cavernous Sinus: Dural branches from ICA and
accessory menigeal branch of the maxillary artery• Posterior Fossa: Dural branches of vertebral, occipital,
and ascending Pharyngeal Arteries
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Location of DAVFAWAD and Little: J Neurosurgery 1990; 72: 839-850
Review of Literature with 377 DAVF cases
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Aggressive / Benign
Transverse/ Sigmoid Sinus 62.6% 1:8.8
Cavernous Sinus 11.9% 1:6.5
Tentorial Incisura 8.4% 31:1
Convexity Sagittal Sinus 7.4% 1:1
Anterior Cranial Fossa 3.7% 2.1:1
Sylvian – Middle Fossa 3.7% 2.5:1
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Classification
• Anatomic Location
• Associated Dural Sinus
• Hemodynamics
• Venous Drainage Pattern• Aggressive / Benign
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Angiographic Classifaction
• Borden• 3 types based on cortical venous reflux and sinus drainage
• Cognard• 5 types based on cortical venous reflux, sinus drainage and
direction of flow with involved sinus
• Barrow• Used for Cavernous sinus fistulas
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Borden Classification(Journal of Neurosurgery 1995; 82:166-179)
Type 1: Anterograde sinus flow and no cortical venous reflux
Type 2: Retrograde sinus flow and cortical venous reflux
Type 3: No flow inside the sinus and exclusive cortical venous reflux
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Cognard Classification(Radiology 194(3): 671-680, 1995
Type 1: Drainage into venous sinus only; anterograde flow
Type 2A: Draining into dural sinus with retrograde flow
Type 2B: Anterograde drainage into sural sinus and CVR
Type 2A & B: Retrograde drainage into dural sinus and CVR
Type 3: CVR only without venous ectasia
Type 4: CVR only with venous ectasia
Type 5: Drainage into spinal perimedullary veins
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Natural History(Interventional Neuroradiology 1997; 3:295-302)
• Aggressive presentation• Intracranial Hemorrhage, Focal Neurologic Deficit or Death
Borden Type 1 2%
Borden Type 2 39%
Borden Type 3 79%
Borden Type 2 & 3 19.2% / patient-year ICH
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Bottom Line
• Presence of retrograde cortical venous drainage is significant prognostic factor for aggressive or unfavorable natural history
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Treatment Options
• Observation• Medical Management• Endovascular
• Transarterial• Transvenous• Liquid Embolic, Coils, Stents
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Treatment Options Continued
• Surgery• Exposure• Ligation, Resection or Disconnection of DAVF
• Stereotactic Radiosurgery• Gamma Knife• Cyber Knife• Novalis
• Combination• Endovascular, Surgery, Radiosurgery
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Management Goals
• Identify which DAVFs are potentially aggressive
• Determine when to treat and which treatment method to use
• Partial vs. Complete obliteration
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Cases
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Case 1Type 1 DAVF
Sigmoid Sinus DAVF
• 52 year old male presents with pulsatile tinnitus and occipital bruit
• Past medical history significant for Nephrotic Syndrome, Antithrombin III deficiency and dural sinus thrombosis
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Case 2High Flow Indirect Carotid Cavernous
Fistula with Exclusive Cortical Venous Drainage
• 71 year old presents with progressively worsening diplopia, left eye chemosis and blurred vision
• Had seen several ophthalmologists
• Increased intraocular pressure
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Case 2 - OutcomeHigh Flow Indirect Carotid Cavernous
Fistula with Exclusive Cortical Venous Drainage
• Full Recovery
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August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas
Case 3High Flow DAVF at the Sinus Torcula
• 21 year old female presents with severe medically recalcitrant headaches and progressive blindness
• Previously diagnosed and treated for pseudotumor cerebri
• Bilateral optic nerve fenestrations
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Case 3 - TreatmentHigh Flow DAVF at the Sinus Torcula
• Staged 3 preop embolizations
• Bilateral Occipital and Suboccipital Craniotomies and intraoperative angiograms
• Gamma Knife Radiosurgery
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Case 3 - OutcomeHigh Flow DAVF at the Sinus Torcula
• Overall excellent
• Developed radiation necrosis 3 years later and lost some vision
• Completed college and now 5 years later, is engaged and in the working world
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Case 4Left Transverse Sinus DAVF with CVR
• 60 year old male presenting to outside hospital with severe headache and visual loss
• MRI: Left Occipital hemorrhage and abnormal flow voids
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Case 4 – Treatment & OutcomeLeft Transverse Sinus DAVF with CVR
• Transvenous embolization
• Full Recovery
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Case 5High Flow Direct CCF
• 27 year old female presents with headache, right eye proptosis and ecchymosis and right temporal bruit
• Patients medical history significant for motor vehicle collision and craniotomy at outside hospital one month before
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Case 6High Flow DAVF with CVR
• 37 year old female presents with right sided weakness and expressive aphasia for one day duration
• Patient’s medical history: Diabetes
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